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Full text of "The science and practice of medicine"







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CORNELL UNIVERSITY 

MEDICAL LIBRARY 

ec — ^ — 

-4- to ITHAOA. DIVISION. 

A 3f 

CHARLES EDWARD VAN CLEEE. M.D. 

B. S. CX)HNEt,r4 UNIVERSITY, '71. 



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THE 



SCIENCE AND PRACTICE 



MEDICINE. 



BY 



WILLIAM AITKEN, M.D., Edin., 

PKOFESSOR OF PATHOLO&Y IN THE ARMY MEDICAL SCHOOL. 



Third American from the Sixth London Edition, 

GREATLY ENLARGED, REMODELLED, CAREFULLY REVISED, AND MANY PORTIONS REWRITTEN ; ADOPTING 

THE NEW NOMENCLATURE, AND FOLLOWING THE ORDER OF CLASSIFICATION OP DISEASES 

PUBLISHED BY THE ROYAL COLLEGE OP PHYSICIANS OF LONDON. 



WITH ADDITIONS 



MEREDITH CLYMER, M.D. (Univ. Penn.), 

EX-PROrESSOR OF THE INSTITUTES AND PRACTICE OF MEDICINE IN THE UNIVERSITY OP NEW YORK ; 
FORMERLY PHYSICIAN TO THE PHILADELPHIA HOSPITAL; ETC., ETC. 



IN TWO VOLUMES, 

WITH STEBL PLATE, MAP, AND ONE HTJNDRED AND EIGHTY •WOODCUTS. 



VOL. L 

PHILADELPHIA: 

LINDSAY & BLAKISTON. 

1872. 

-r 

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Entered according to Act of Congress, in the year 1872, 

By LINDSAY & BLAKISTON, 

In the Office of the Librarian of Congress, at Washington, D.C. 



SBEBMAN & CO., PRINTERS 



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THE MEMORY 



SIR JAMES CLAEK, M. D. (Edin.), K. C. B., F. R. S., 

EAEONET OF THE UNITED KINGDOM. 

Born December 14, 1788, and Died June 29, 1870, 

WHOSE LIFE "WAS A SUBORDINATION OF SELF TO PUBLIC INTEREST, TO THE ADVANCEMENT OF 

SCIENCE AND OF HUMAN PROGRESS A LIFE OF DEVOTION TO THE QUEEN — A LIFE 

WHOSE INFLUENCE WAS LARGELY FELT AND WISELY EXERCISED IN THE 

ADVANCEMENT OP GENERAL AND OF MEDICAL EDUCATION — AND, A 

LIFE WHOSE CONDUCT REMAINS A MODEL TO PUBLIC MEN. 

I 

Professionally, he largely contributed to promote, by exalting, the office of the 
Physician, by establishing the aim of the Science of Medicine as the means of Pre- 
venting Disease ; for " he was one of the earliest of those who saw the importance of 
Sanitary Science,,and one who was ever ready with time, thought, and influence, to 
aid its progress." To accomplish this end he secured the appointment and nomination 
of the first Health of Towns' Commission ; and he lived to see the hygienic measures 
he so zealously advocated, and was the main agent in securing, put into legal shape 
and active operation, first in most of our large towns and cities, and second, in reform- 
ing the hygienic regulations of Her Majesty's British and Indian Array and Navy; 
thereby helping to effect a great saving of human life — Civil, Military, and Naval — 
in every region of the world. 

He mainly aided to establish the College of Chemistry, " which has done so much 
to diffuse among our manufacturing and agricultural population a knowledge of 
applied chemistry, and to advance the Science by original research." 

He was especially earnest in the establishment of the Army Medical School, now 
stationed at Netley, for the special training of medical men in Military and Naval 
Professional duties ; and he continued to the last moment of his life to take the warm- 
est interest in everything connected with that institution. 

As a Member of the Senate of the London University, and always taking an active 
interest in education, he pointed out defects in Medical .education which have since 
been removed, particularly as to " making examinations as practical and thorough as 
possible ;" by bedside examination in Practical Surgery and Medicine — a method now 
generally adopted in testing the qualifications of candidates for a license to practice 
in civil life ; and in competitive examinations for those who seek to enter the military 
and naval services. He greatly aided (in 1842), in improving medical teaching, by 
pointing out to the Government of the day the urgent need for " a good and uniform 
system of Medical Education, which should be the same throughout the empire for 
every medical practitioner." 



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IV DEDICATION. 

" Modest in his nature, and singularly indifferent as to the recognition of his ser 
vices, provided the end was gained, he desired not that his share in it should he known ; 
so that much of what he did is scarcely now known ; and few, men knew the extent of 
his acquirements" (Obituary Notice, Royal Soc. Proceed., No. 126). 

Widely he laid the foundation of his medical knowledge and experience at home 
and abroad — and widely has that experience been beneficial to mankind — which, com- 
bined with great benevolence of character, made him so excellent a Physician, and 
secured for him the highest position in the medical world. 

He lived for many years to enjoy his retirement from the active practice of his pro- 
fession, continuing almost to the last hour of his life to take the warmest interest in 
every question connected with the improvement of our Schools of Medicine^the prog- 
ress of Hygienic Measures for the Prevention of Disease — the practical application of 
scientific knowledge for the improvement and happiness of his fellow-men and the 
promotion of human progress. 

The author was privileged by permission, in 1863, to dedicate to Sir Jambs Clark 
the Second Edition of this work ; and now, in 1871, he dedicates to His Memory this 
Sixth, hut still imperfect attempt to teach in a text-book the Science and Practice 
OF Medicine. 



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PREFACE TO THE THIRD AMERICAN EDITION. 



The appreciation of Dr. Aitken's " representative book," as a 
full and fair exposition of the Medical Art and Science of the 
day, by the profession of this country, has been abundantly 
shown by the sale of two American editions. 

The present, and third, American reprint is from the sixth 
London edition, which has been carefully revised, and in part 
rewritten. The incorporation by the Author of about four- 
fifths of the matter of the Editor in the last American edition, 
either in form or in substance, has rendered his duties compara- 
tively light in the present one. Besides new material in the 
chapters on Fevers, and Diseases of the Nervous System, there 
are additional articles by the Editor on : Camp Measles, Spinal 
Symptoms in Typhoid Fever, Typho-Malarial Fever, Chronic 
Malarial Toxcemia, Epidemic Cerehro-Spinal Meningitis, Chol- 
era Morbus, Cholera Infantum, Chronic Alcoholism, Delirium 
of Inanition, Chronic Fycemia, Syphilitic Disease of the Liver, 
Shaking Falsy, Myo-Sclerosic Paralysis, and Cerehro-Spinal 
Sclerosic Paralysis, &c. 

The Editor's additions are thus designated [ ]. 

65 West Thirty-eighth Street, New York, 
August 1, 1872. 



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PKEFACE TO THE SIXTH EDITION. 



FouETEEN years have passed away since the first edition of 
this work was published ; and five editions of it having been so 
favorably received since that time, I trust that this — the sixth 
edition — may deserve and continue to retain the confidence alike 
of Students of Medicine, of Teachers, and of the Profession. 

I have conscientiously endeavored to make each addition an 
improvement on its predecessor ; and as with previous editions, 
so with this one, I have aimed at giving as faithfully and as fully 
as I can, the ideas and the views of the more advanced and able 
Physicians of the time, desirous that this text-book should be 
"a representative book" of the Medical Science and Practice of 
the day, as actually understood and followed by the best men of 
our profession. 

It aims, indeed, at being a text-book for Students of Medicine, 
following such a systematic arrangement as will give them a con- 
sistent view of the main Facts, Doctrines, and Practice of Medi- 
cine in accordance with accurate physiological and pathological 
principles and the present state of Science. 

During the past eighteen months I have been engaged in a 
careful revision of the whole work (which has been out of print 
nearly twelve months) ; and stimulated by the great encourage- 
ment I have received, I have spared no exertion to improve it 
and make it worthy of continued confidence, as orthodox in its 
aim and practical in all its details. 

The plan of the work has been again remodelled, so as to 
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viii PREFACE TO THE SIXTH EDITION. 

embrace a consideration of the topics in the order of the classi- 
fication of the College of Physicians of London, whose nomen- 
clature I had already followed in the last edition, thereby tend- 
ing to remove the difficulties which arise from the complexity 
and indefiniteness of medical terminology. 

It is still, however, a subject of regret that the medical pro- 
fession do not adopt a uniform system of Nosology — so essential 
for the purposes of Diagnosis and the Registration of Diseases 
and of Deaths — indeed, altogether " indispensable for the gath- 
ering in of trustworthy statistical information and knowledge 
respecting disease." 

Fully impressed as I am with the necessity for such uniformity 
of nomenclature, the profession cannot hope to see it secured 
unless a uniform system of naming diseases be taught in the 
Schools of Medicine. To aid in this education, I have endeav- 
ored to adhere closely to the new nomenclature, more especially 
as it has become the authoritative nomenclature of the country. 

The Secretary of State for War, the Board of Admiralty, and 
the Secretary of State for India have all and severally adopted 
the work of the College of Physicians, and have distributed it 
to the medical officers of their respective departments. 

It is now also put, at the expense of Her Majesty's Govern- 
ment, into the hands of every registered practicer of medicine 
in England, Scotland, and Ireland. 

Thus, issued with the stamp of authority, its use is secured in 
the records of all the public services — most of the large public 
hospitals of the country having previously adopted, spontane- 
ously, the new nomenclature and classification. 

It would now also be a good example if the Fellows of the 
London College of Physicians would themselves individually 
adhere steadily, in their published writings, to their adopted and 
accepted nomenclature. 



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PREFACE TO THE S'lXTH EDITION. IX 

The amount of matter contained in these volumes has very 
greatly increased — an increase which implies many more con- 
siderable changes (which it is hoped are improvements), as well 
as additions, than can be made obvious in a preface. The addi- 
tions and changes thus made are widely and generally distributed 
throughout every chapter of the book. 

Compared with the previous edition, the new material added 
in the present is equivalent in bulk to a third volume added to 
the last edition ; yet the size of the work is not increased, as a 
special font of type was cast to enable the printer to preserve 
clearness without adding to the bulk of the volumes. 

Thus I have endeavored to embody an account of all the more 
recent advances in the Science and Practice of Medicine, which 
during the past fourteen years have been unusually numerous 
and important. Many chapters have been to a great extent re- 
written and remodelled, many new topics have been added, and 
every part has been thoroughly revised. 

The subjects composing Part I have been greatly expanded 
by " topics relative to pathology and morbid anatomy," which 
the classification of the College of Physicians rendered it neces- 
sary to notice as introductory to succeeding parts. Numerous 
additions have also been made where topics of importance had 
only been shortly noticed before ; while the sections on the Pre- 
vention and Treatment of Diseases have been more fully consid- 
ered and expressed. 

The work has been to a great extent, indeed, rewritten ; and 
descriptions of many diseases, altogether omitted in former edi- 
tions, are now introduced — so much has the new nomenclature 
and classification done to render uniform and to consolidate in- 
formation relative to diseases ; and to render necessary a notice 
of topics which otherwise were lost sight of from the absence of 
that consolidation and uniform connection which the authority 
of the College of Physicians has now given by their classifica- 
tion of diseases, and which no single person could have accom- 
plished. 



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X PREFACE TO THE SIXTH EDITION. 

The diagrams illustrative of the typical ranges of body-tem- 
perature in febrile diseases (which were given in the third edition 
of this work, in 1863, for the first time in a text-book) have 
been carefully reconsidered, together with the whole of this im- 
portant and practically useful subject now so generally adopted. 
The result has been that the diagrams have all, with few excep- 
tions, been redrawn and cut upon an improved model. Addi- 
tional woodcuts have been also introduced wherever it was 
thought they would render the descriptions in the text more in- 
telligible. 

In accomplishing this work I have again many obligations to 
acknowledge, as on former occasions, and especially to many kind 
fellow-workers in the profession, whom I do not personally know, 
but from whom I have received most useful hints in their oblig- 
ing communications, to be remembered by me with gratitude, 
and from which this edition has profited much. 

To my friend, Staff'-Surgeon Dr. Blatherwick, in charge of 
the large Lunatic Hospital at Netley, I am indebted for many 
valuable notes and practical suggestions concerning "Disorders 
of the Intellect." 

To Dr. Balthazar W. Foster, Professor of Medicine in Queen's 
College, Birmingham, and Physician to the General Hospital of 
that town, I am under great obligations for his kind revision of 
the sections relating to the use of the " Sphygmograph," for much 
valuable new matter and new " Sphygmographic Tracings" in 
the sections on "Diseases of the Heart and Arteries." 

To Dr. Morell-Mackenzie, Physician to the London Hospital, 
and to his Assistant, Mr. Lennox Browne, I have to acknowledge 
the kind assistance given me in the sections where the "Laryn- 
goscope" is described and applied to the diagnosis and treatment 
of "Diseases of the Throat and Larynx," and for which Mr. 
Lennox Browne has kindly executed new woodcuts ; while the 
text is partly based on the MSS. of Dr. Mackenzie's Lectures on 
"Diseases of the Throat," delivered at the London Hospital. 



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PREFACE TO THE SIXTH EDITION. XI 

To my friend Dr. T. W. Anderson, of Glasgow, I also owe 
my thanks for the woodcuts of parasitic diseases of the skin. ^ 

My thanks are also again especially due to my friend Dr. 
Thomas Graham Balfour, F.R.S., the Chief of the Statistical 
Branch of the Army Medical Department, for his kindness in 
revising and correcting the part on "Medical Geography." To 
him, to Dr. Henry Marshall, and to the late Sir Alexander M. 
Tulloch, science is largely indebted for our knowledge regarding 
"Medical Geography ;" and to the joint reports of these men 
may fairly be assigned the merit of having first called the atten- 
tion of the military authorities to the actual condition of the 
army in regard to health, and to the various deteriorating agen- 
cies by which the soldier comes to be affected in different regions 
of the world. That so distinguished an authority as Dr. Balfour 
should have been so kind as to revise that portion of my work 
which treats of these topics, as he has kindly done for all the 
previous editions, demands from me the most grateful acknowl- 
edgments. 

William Aitken. 



KoTAL Victoria Hospital, 

Nbtlet, November, 1871. 



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CONTENTS OF VOLUME I. 



PAET I. 



TOPICS RELATIVE TO PATHOLOGY AND MORBID ANATOMY. 



CHAPTER I. 

Ov Medicine as a Scibnck and as an Art : its Objects and its Extent, 

Medicine to be Studied as a Science and as an Art, 

Medicine considered as a Science, 

Medicine considered as an Art, 

Topics of Human Knowledge which make up the Science of Medicine, 
Division of the Science into the Departments of — (1.) Physiology 

Pathology; (8.) Therapeutics; (4.) Hygiene,. 
The " Institutes," " Institutions," or " Theory of Medicine,", 
Principles of Pathology the most useful Guide to the Student, 



PAGE 

. 49 

. 49 
. 49 
. 49 



(2.) 



49 
50 
50 



CHAPTER II. 

'B.ow THE Province ov Pathology is Mapped Out, 50 

Inquiry into the Nature or Pathology of Diseases embraces certain Topics : . 50 

1. Accurate Observation and Correct Registration of Pacts in Pathology, 50 

2. Descriptive Pathology, General and Special, 50 

Range or Province of Special Pathology, 50 

Range or Province of General Pathology, 50 

Accuracy of Observation the First Lesson for the Student to Learn, . . 50 

Registration of Pacts in Pathology in Authentic and Permanent Forms, . 51 

(a.) History of Cases of Disease from their Origin to their end ; (b.) 

Statistics of Disease, 51 

Range or Province of Speculative Pathology, 51 

Province of Pathology to Dictate the Maxims of Rational Practice, . . 51 
Subjects Treated of in the first part of this Work, and General Plan of this 

Text-book 51 



CHAPTER III. 

Relative Nature of the Terms "Life," "Health," "Disease," . . 52 

52 
52 
52 
52 
52 
52 
52 



Meaning implied by the Terih " Disease," 
Meaning implied by the Term "Life," . 
Conditions of " Health" have considerable Latitude, 
Many Degrees of Feebleness and Delicacy of Health, 
Indefinite Notions of "Normal Life," . 
Indefinite Notions of " Disease," .... 
Elements Required in a Definition of any State of Disease, 



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Xiv CONTENTS OF VOLUME I. 



CHAPTER IV. 

PAGE 

How THB Nature and Oattses of Diseases mat be Elucidated, . . 53 

Aspects under which Diseases may Idb Studied, 53 

1. Clinical Investigation and Instruction, 53 

Natural History of Diseases a Special Subject of Study, 53 

2. Special Pathology or Special Nature of Particular Diseases, . . 53 

3. Primary Elements' of Disease or General Pathology, . . . .53 

Subjects for Investigation by the Student, .... . . 53 

Symptoms of Disease [Sympiomatology), and how Symptoms are Converted 

into Signs, 53 

Causes of Disease (Etiology), 53 

Localities of Disease (Pathogeny), 53 

Morbid Alterations in Textures (Lesions and Morbid Anatomy), . . .53 
Elementary Constituents of Disease (Mo?'6iiijEKstoioyy), 53 



CHAPTEE V. 

Oi' Morbid Phenomena, Symptoms, and Signs op Disease, . . . .53 

Meanings attached to the Terms "Symptom," "Sign," and "Diagnosis,"' . 53 
How "a Diagnosis is made" by the Conversion of "Symptoms" into 

"Signs," 53 

How " a Prognosis is made " by Forecast of Events, 54 

Symptoms which are Pathognomonic of Disease 54 

Methodical Examination of Patients necessary, 54 

Works recommended for Study, 55 



CHAPTER VI. 

Morbid Anatomy and Pathological Histology : the Special Means and 
Instruments by which the Nature of Diseases may be Investi- 
gated, 55 

Definition and Province of Morbid Anatomy, 55 

Morbid Anatomy is a record of Facts, ,55 

Relation of Morbid Anatomy to Pathology, 55 

Morbid Anatomy and Pathological Histology, .55 

Medicine as a Science is Influenced by the Details of Morbid Anatomy, . 55 

Historical Retrospect of Morbid Anatomy, .56 

Practice of Medicine Dictated by Physiology and Nature of Diseases, . . 56 
Physiology the Basis of Pathology, . . . . ' . . . .57 

How the Science of Pathology is being Advanced, 58 

Delicate Physical Instruments of Research 58 

'Organic Chemistry and Histology, 58 

Oharacteristics of Medical Research, 60 

Probation and Progress Characteristic of the Practical Medicine of the day, 60 
Province of Morbid Anatomy* as now distinctly Defined, ... 
Objects of the Science of Pathology, 



2 



CHAPTER VII. 

The Elementary Constituents oe Lesions, as shown by Morbid Anatomy 

AND other Means of Research, 63 

The Material Effects or " Stamps " of Disease, 63 

Means and Instruments of Research for the Investigation of these Changes, 63 

Every opportunity to be taken of making Post-mortem Examinations, . . 64 

Forms of the Constituent Elements of Disease, 64 

A. Morbid Elementary Products, 65 

B. Complex Vital Processes whose Phenomena, more or less combined. 

Constitute Diseases and Lesions, 66 

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CONTENTS OF VOLUME I. XV 

CHAPTER VIII. 

PAGE 

Description of Complex Morbid States 67 

Catarrh, g7 

Definition of Catarrh .67 

Pathology and Anatomical Characters of the Disease, 67 

Regions of Local Catarrh, 67 

Evidence of Chronicity of Catarrh, . 67 

Kesults of Catarrh, 07 

Inflammation, 68 

Definition of Inflammation, .......... 68 

Pathology of Inflammation, .68 

Phenomena and Theory of the Inflammatory Process 69 

Altered Conditions of Healthy Nutrition, 70 

I. Alteration of Blood Supply and Bloodvessels, 70 

Redness of Inflamed Parts, . . . . . . . . . .71 

Dilated Bloodvessels in Inflammation, 72 

Determination of Blood to a Part, 72 

Active Congestion, 72 

Condition of the Capillaries in Inflammation, 73 

Professor Strieker's Observations, 73 

Dr. William Addison's Observations regarding the White Corpuscles, . . 73 

Dr. Augustus Waller's Observations, 73 

Cohnheim's Experiments and Observations, 73 

Soft, Yielding, and Permeable Nature of Living Capillaries, . . .73 
Passive Congestion, . . . . . • , . . . . . .74 

" Determination " and " Congestion " resulting from Irritation, . . .,74 
II. Altered Constitution of the Blood as regards its adaptability to nourish the 

part, 74 

The Altered State cannot be Chemically expressed, but may be Microscopi- 
cally Demonstrated in relation to the State of the Tissues, . . .74 

Local Changes at the Inflamed Part, 74 

Tendency of the Blood-corpuscles to Bun into Piles or Rouleaux, . . .75 
The Yield of Fibrin in Inflamed Blood and in certain Diseases, . . .75 

Fibrinous Coagula in Bloodvessels, 75 

Results of Fibrinous Coagula in Bloodvessels, 75 

Primary Seat of the Inflammatory Process, 76 

■ Effects of Irritants on Minute Elements of 'Tissue, 76 

" Resolution " of Inflammation, 76 

Structural Elements of Minute Arteries, 76 

Structure of Capillaries, 77 

Cause of Stasis or Stoppage of the Blood and Exudation of Liquor Sanguinis, 77 
Theories regarding these Phenomena, ........ 77 

Theory of Henle — the Neuro-Pathological Theory, 77 

Simon's View opposed to Reflex Action, and in favor of a Direct Change 

affecting Blood, Blood-nerves, and Molecular Structure, . . . .77 
Bennett's Belief in a Vital Force acting outside the Vessels, . . . .77 
Paget and Lister's Belief in a Mutual Relation between the Blood, the Ves- 
sels, and the parts around, 77 

Dr. C. J. B. Williams's Belief in the Accumulation and Adhesive Properties 

of White Globules, . . . . _ 78 

Rokitansky and Wharton Jones's Explanation, 78 

Parenchymatous Inflammation of Virchow, 78 

Example of Parenchymatous Inflammation, 78 

Observations of Goodsir, Allison, Simon, Virchow, and Lister, . . .79 

Products, Effects, or Events of Inflammation, 80 

Local Growth of Cells, 80 

Process of Resolution, 80 

Phenomena of " Delitescence " and " Metastasis," 80 

Phenomena of Exudation and accompanying Changes, 80 

Productive Effects of Inflammation, 81 

Inflammatory Effusions or Exudations, 81 

(l.J Serous Effusions and Examples of such, 81 

Essential Characteristics of Inflammatory Effusions, . . . .82 
Site of Serous Effusion sometimes an Element of Danger, . . .82 



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XVI CONTENTS OF VOLUME I. 

\ ' 

PAGE 

(2.) Blood Effusions or Extravasation, 82 

Post-mortem Evidence of Extravasation, 82 

(3.) Inflammatory Lymph or Fibrin, . 82 

Typical Elementary Forms of Growth in Lymph, 83 

. Circumstances Modifying the Type of the Inflammatory Process, . . 83 
Granular, Molecular, or Fibrillated Development of Fibrinous Products, 83 
Corpuscular Forms of Fibrinous Products, . . . . . .83 

Fibrinous and Croupous Forms, . . . . . . . .83 

Plastic and Aplastic Forms, .83 

Adhesive or Lymphy Inflammations, 84 

False, Adventitious, or Pseud'o-membranes 84 

Dysmenorrheal Membranes, . . .• 84 

Corpuscular Forms seen in Lvmph-cells, Chyle and White Corpuscles of 

Blood, . . . " 84 

Lymph of Herpes, ■ . . . .84 

Primordial Cell-forms of Inflammation — their Modes of Growth and De- 
generation of Lymph, as described by Sir James Paget, . . . .85 
Compound Granule-cell, Granule-cell, and Pus-corpuscles, . . . .85 
Formation of the Compound Granule-cell, and Mode of its Disappearance 

and its Use or Function, 86 

The Swelling of Inflammation and its Cause, 87 

Local and General Symptoms of Inflammation, 87 

Local Generation of Heat, 87 

I. Inflammatory Fever, Symptomatic Fever, or Sympathetic Fever, . . .87 
(1.) Condition of Nervous System in Inflammatory Fever, . . .88 

(2.) Condition of the Vascular System, 88 

(3.^ Condition of the Respiratory System, 88 

, (4.) Condition of Digestive System, ........ 88 

(5.) Condition of the Secerning System, . . . . . . .88 

(6.) Condition of the Nutritive Functions 88 

Date of Febrile Disturbance, 88 

General Conclusions as to Febrile Symptoms, . . . . .89 
Symptoms of Suppuration, ......... 89 

Asthenic and Sthenic Indications, .89 

Production of Pus, .......... 90 

II. The Typhoid Fever of Inflammation, 90 

Its Type, Asthenic or Adynamic, ........ 90 

Nervous or Ataxic Symptoms, . . . . , . . . . .90 

Causes of Inflammation, 90 

(1.) Determining or Exciting Causes, 90 

(2.) Predisposing Causes, 90 

Irritation, the Starting-point of Inflammation, 90 

Causes of Irritation Classified, ......... 90 

Nerve Fibres having a Special " Trophic " Function, . . . .91 

(3.) Predisposing Causes Classified, • . , .91 

tjLCERATIVB INFLAMMATION, 91 

Definition of Ulcerative Infiammation, .91 

Pathology of Ulcerative Infiammation, 92 

Formation of an Ulcer, 92 

Meaning of the terms " Ulceration," " Abrasion," and " Excoriation," . 92 

Appearance of Granulations, . . . 92 

Three Processes which Progress to Ulceration, namely : Exudation, Growth, 

and Liquefaction, ........... 92 

Healing by Granulation, ti2 

Healing by Second Intention, . 92 

Process of Granulation, '. 92 

Grafting or Transplantation of Germ? of Skin, . . . . . .93 

Eepair of Parts by Granulation, . . i . 93 

Eeproduction of Original Tissue, how far it is accomplished, . . . .93 

Nature of Cicatrix Tissue, 93 

Sites of Ulcerative Inflammation, 93 

SupptJKATivB Inflammation, .'.... 94 

Definition of Suppurative Inflammation, . 94 

Pathology of Suppurative Infiammation, 94 

Evidence of Formation of Pus from Pre-existing Germinal Matter, . . 94 

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CONTENTS OF VOLUME I. Xvii 

PAGE 

Mucinous Exudation appertains to certain Parts, 94 

JW«c«s as a Characteristic of Inflammation, 94 

Formation of Pus — Suppuration 94 

Description of the Pus-cell, . 95 

Good, Healthy, Praiseworthy Pus — Pus Laudabile, 95 

Suppuration taljes place under Three Conditions, 95 

(1.) Circumscribed Suppuration, 95 

An Abscess, Boil, or Phlegmon, .95 

Pyogenic Membrane, 95 

Old or Chronic Abscesses, 95 

Purulent Effusion into Cavities, 95 

(2.) Diffuse Suppuration, or Purulent Infiltration, 95 

Formation of " Sloughs " and " Sinuses," 96 

Pointing of a Phlegmonous Abscess, . 96 

(3.) Superficial Suppuration and Examples, .96 

Proliferation, 96 

Pus-cells, Mucus and Epithelial Cells, Anatomically but not Physiologically 

Equivalent, 97 

Process of Growth and Origin of Deepseated Pus-formation, ... 97 

T^o Different Modes of Pus-formation to be Distinguished, .... 97 

Parenchymatous Inflammation, and Secretory Inflammation, ... 97 

" Centres of Nutrition "of Goodsir, 97 

Three Events of Inflammation, 97 

Softening or Diminished Cohesion of Tissue, 97 

Interstitial Absorption, 98 

Pointing of ah Abscess, . . 98 

Hectic J?ever and its Distinguishing Characters as the Result of Prolonged 

Pus-formation, . .98 

Type of Hectic Fever, 98 

Symptoms of Hectic Fever, 98 

Description of Hectic by Dickens — (Death of Smike), . . . . . 99 

Diagram of Body-Temperature in a Case of Hectic Fever, .... 100 

Plastic Inflammation, 101 

Definition of Plastic Inflammation, ........ 101 

Pathology of Plastic Inflammation, 101 

Soft Lymph of Plastic Inflammation, as seen Growing from Serous Mem- 
branes, 101 

Sir James Paget's Description of the Process, 101 

Changes in the Elements of Lymph, 101 

Process of " Proliferation," 101 

Proliferation of Lymph-cell Elements from Inflamed Pleura, . . , 101 

Nuclei in the Fibrinous Products of Lymph developing into Fibres, . . 102 

Fibro-Plastic Cells in Lymph developing into Fibres, 102 

Perfect White Fibrous Tissue from Lymph, 102 

Elements in the Lymph of Plastic Inflammation, . . . . .. ,. 102 

Rhbumatic Inflammation, 103 

Definition of Rheumatic Inflammation, . ....... 102 

Pathology of Eheumatic Inflammation, 102 

Textures Implicated in Eheumatic Inflammation, . ^ 102 

GoTTTY Inflammation, . . . . , 103 

Definition of Gouty Inflammation, . 103 

Pathology of Gouty Inflammation, 103 

Gonokkhceal Inflammation, 103 

Definition of Gonorrhoea! Inflammation 103 

Pathology of Gonorrhoeal Infiammation, 103 

Peculiarities of Gonorrhoeal Inflammation, . . . . . . .103 

Gangrene, . • • ^^^ 

Definition of Gangrene, • 104 

Pathology of Gangrene, .... 104 

Sphacelus, Caries, and Necrosis, 104 

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XVIU CONTENTS OF VOLITMB I. 

PAGE 

Slough, Sequestrum, and Process of Sloughing, 104 

Humid Mortification and Formation of Phlyctenie, . . . . 104 

Dry Mortification, as from Ergotism, 104 

Gangrene to be distinguished from Degeneration, . . ... 105 

"Suspenned Animation " of Parts, 105 

PaSSITB CONGBSTIOlf, 105 

Definition of Passive Congestion, 105 

Pathology of Passive Congestion, or Hypersemia, 105 

Active and Passive Congestion to be distinguished, 105 

Confusion regarding the use of the term Congestion, 106 

Eelations between Active and Passive Congestion, 106 

Examples of Mechanical Congestion, . . . . . . . . 106 

Results of Mechanical Congestion of Veins, 106 

Passive Congestion: how it differs from Mechanical Congestion in Seat and 

Cause, 107 

Examples of Passive Congestion, and Combinations of the two Porms, . 107 

Results of Passive Congestion, . . . 108 

Eedness of Passive Congestion, . 108 

Summary of the Causes of Passive Congestion, 108 

Extravasation or Blood in Hemokrhaqb 108 

Definition of Extravasation of Blood, . 108 

Pathology of Hemorrhage — Spontaneous or Traumatic, .... 108 

Hemorrhage by Exhalation of Blood, or Hemorrhage without Eupture, . 108 

Examples of Hemorrhages from Mechanical Obstacles to the Circulation, . 108 

Examples of Active and Passive Hemorrhages, 109 

Seats of Hemorrhage and Technical Names of the Hemorrhages, . . 110 

The Effects of Hemorrhage and Signs of Danger from it, . . . . 110 

Examples of Secondary Hemorrhages, ........ 110 

Conversion of Hydrocele into Haematocele, . . . . . . . Ill 

Cause of Hemorrhagic Pericarditis, Ill 

Hemorrhagic Diathesis, Hemophilia. Hsemorrhaphilia, Hsemorrhophilis — a 

disposition or constitutional liability to habitual hemorrhage, . . Ill 

Molimina Hsemorrhagicum, .......... Ill 

Symptoms of the Constitutional Tendency to Bleeding, .... Ill 

Congenital or Acquired Constitutional Tendency to Bleeding, . . . Ill 

Its Hereditary Transmission an instance of Atavism, 112 

Kelation of the Diathesis to Scrofula and Scurvy, . ..... 11"2 

Special Hemorrhages and their Nomenclature, ....... ll-S 

Results of Blood Extravasation, 113 

Pigment in Apoplectic Cicatrix 113 

Crystals of Hjematoidin in Different Forms, 113 

Prognosis in Cases of Hemorrhage, ........ 114 

Treatment of Hemorrhage in Cases of Hemorrhagic Diathesis, . . . 114 

Dropsy, " . 115 

Definition of Dropsy, 115 

Pathology of Dropsy, . 115 

Nature of the Fluid of Dropsy, . 115 

Difference between Inflammatory and Dropsical Effusions, . . ... 115 

Nomenclature of Dropsies, . 115 

Constitution and Analysis of Dropsical Fluids, . . . . . .116 

Origin of Dropsy, . 116 

Wateriness of the Blood [Hydrcemia), 116 

Combined Conditions Productive of Dropsy, 116 

Distinction between General Dropsy and Local Dropsy, .... 117 

Cardiac Dropsy (Dyspnoea), . . , 117 

Kenal Dropsy, 117 

Local Dropsy (Ascites) (Cirrhosis), 117 

(Edema of Lungs (Mitral Obstruction), . ., 117 

(Pneumatosis), 118 



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CONTENTS OP VOLUME I. xix 

PAGE 

Fibrinous Deposit, X18 

Definition of Fibrinous Deposit, Hg 

Pathology of Fibrinous Deposit, Hg 

Theories regarding the Production of Fibrinous Deposits, . . . ! 118 

Polypi, Fibrinous Vegetations, and Emboli, 119 

Alteration op Dimensions 119 

Definition of Alteration of Dimensions, 119 

Pathology of Alteration of Dimensions, 119 

[a.) Dilatation and its Definition, . . 119 

Pathology of Dilatation— Active Dilatation, Simple Dilatation, and 

Passive Dilatation, Ug 

Causes of Dilatation of Hollow Organs, ...... 119 

How Dilatation tends to' Destroy Life, 119 

(6.) Contraction and its Definition, 120 

(c.) Htpertropht and its Definition, 120 

Pathology of Hypertrophy, 120 

Conditions Essential for Hypertrophy, 120 

Diagrams illustrative of the Distinction between Hypertrophy and 

Hyperplasia, 121 

(d.) Ateopht, 122 

Definition of Atrophy, 122 

Pathology of Atrophy, . . . 122 

Senile Atrophy, ' . . 122 

Progressive Muscular Atrophy, ........ 122 

Phthisis, Consumption, Marasmus, 122 

Degeneration, 122 

Definition of Degeneration, .......... 122 

Pathology of Degeneration, 122 

Separation of Degeneration from Substantive Diseases, .... 122 

Sir William Jenner's Account of the Nature of Degenerations, .- . . 122 

The Characteristics of Degeneration, 123 

Histolysis, 123 

Degenerative Changes to be distinguished from Inflammation, . . . 123 
How the Recognition of Degenerative Changes has influenced the Practice 

of Medicine, . . . ' . 124 

(a.) Fatty Degeneration — the most widely spread, 124 

Examples of Fatty Degeneration, 124 

(b.) Mineral Degeneration distinct from Ossification, 126 

Petrified Tissue — Petrifaction or Calcification, 126 

Examples of Mineral Degeneration, 126 

(c.) Pigment Degeneration — Pigmentation, . . . . . . . 127 

Examples of Pigment Degeneration, 127 

Melanasmia, 128 

Post-mortem Evidence of Pigmentation, ...... 128 

Origin of Blood-crystals, ......... 128 

Crystals of Haematoidin, 128 

Crystals of Hsemin, . -. 128 

Crystals of Hsemato-Crystalline, ........ 129 

(d.) Fibroid Degeneration, . 129 

Examplesof Fibroid Degeneration, 129 

IiARDACEOirs Disease, 129 

Definition of Lardaceous Disease, 129 

Pathology of Lardaceous Disease, 130 

Nomenclature of Lardaceous Disease, 130 

Chemical and Micro-chemical Investigation of Lardaceous Disease, . . 130 

Directions which the Investigation of Lardaceous Disease have taken, . 130 



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XX CONTENTS OP VOLUME I. 

PAGE 

Chemical Nature of the Lardaceous Lesion, ' . 130 

Nomenclature of the Disease from its supposed Chemical Nature and Alli- 
ances, 132 

Albuminoid : Nature of the Substance, 132 

General Character and Anatomical Description of Tissues affected with Lar- 
daceous Disease, 133 

Beaction with Iodine, . 134 

Composition of Iodine Test for use in Post-mortem Koom, .... 134. 

Elements of Tissuie in which Lardaceous Disease has been Demonstrated, . 134 

Diseased States with which Lardaceous Disease has been found associated, 135 

Dr. Dickinson's View regarding the Nature of Lardaceous Disease, . . 135 

Clinical History of Lardaceous Disease, . . . . . . . . 136 

Signs or Symptoms associated with Lardaeeous Disease, . . . .136 

Ctst .137 

Definition of Cyst, ■. ... 137 

Pathology of Cyst, . . ..137 

Theories regarding the Formation of Cysts, . . . '. . . . 137 

Three Modes of Cyst Formation, 138 

(A.) Simple or Barren Cysts, 139 

(B.) Compound or Proliferous Cysts, ........ 139 

Examples of Simple or Barren Cysts, 139 

(a.) Gaseous Cysts (Pneumatoses), 140 

(b.) Serous Cysts, or Hygromata, 140 

Nature of the Contents of Serous Cysts, 140 

Usual Situation of Serous Cysts, 140 

" Hydroceles of the Neck," . . . 140 

Instance of Serous Cyst Development Proving Fatal, .... 141 

Congenital Character of some Serous Cysts, 141 

Cys.ts in the Gums and Mamma, ' . . 141 

(c.) Synovial Cysts, 142 

Three Modes of Formation, ; 142 

(d.) Mucous Cysts, 142 

Examples of Mucous Cysts, and Microscopic Character of Contents, . 142 

(e.) Kanula, • 142 

(f.) Sanguineous Cysts, 142 

(g.) Cysts containing Oil or Fat, 142 

(h.) Colloid Cysts, ............ 142 

(C.) Proliferous or Compound Cysts, . . . . . . . . 142 

Example of Complex Ovarian Cysts, 142 

Parasitic Disease, 143 

Definition of Parasitic Disease, 143 

Pathology of Parasitic Disease, . . 143 

Nature of Blight, 143 

History of Parasitic Diseases, 143 

Elementary Facts regarding Parasitic Disease, 144 

Hypothesis of " Spontaneous Generation," 145 

Wide Kange of Study required to obtain a Knowledge of Parasitic Disease, 145 ■ 

Classified List of Human Parasites, 146 

Distinction between Mature and Immature Parasites, 147 

Habitat of the Sexually Mature Entozoa, I47 

Cystic or Vesicular Entozoa to be distinguished ; Non-vesicular Parasites 

Inclosed in' Cysts, 148 

Examples of such Distinctions, 148 

Process of Fecundation and Development of Ova, ...... 148 

Migration of Parasites, 148 

Examples of Alternate Generation or Metagenesis, 148 

Lesions and Diseases caused by Parasites, ....... 149 

Cerebro-spinal Symptoms caused by Parasites, 149 

I. — Entozoa, I50 

Class A. — Ccblelmintha, ok Hollow Worms, 150 

Definition of this Class of Worms, . . 150 

Pathology of the Coalelmintha, . .' 150 

A Knowledge of the Generation of these Worms necessary, .... 150 

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CONTENTS OF VOLUME I. XXI 

PAGE 

Tertility of the Round Worms enormous, I50 

Description of the Ova and Organs of Generation in Eound Worms, . . 150 

Development of the Ova in Water, 150 

Period of Incubation of the Ova, 151 

1. Description of the Ascaris Lumbricoides 152 

2. Description of the Ascaris Mystax, 152 

3. Desci'iption of the Triohocephalus Dispar, . ...... 152 

4. Description of the Trichina Spiralis, 153 

Its First observed Occurrence in the Human Body 153 

Examples of the Parasite in the Encysted and non-Encysted State, . . 154 

Drs. Cobbold's and Leuckart's Account of the Parasite, .... 154 
Symptoms in the Human Subject induced by the existence of Trichina 

Spiralis, ............ 155 

History of Cases of its Occurrence in Man, ..... 155-159 

Its Occurrence in the Flesh of certain of the Lower Animals, . . . 156 

Its frequent Occurrence in Subjects brought to Dissecting-Eooms, . . 157 

History of the Development of the Parasite, 157 

Occurrence of Severe Cases in Germany 158 

Occurrence of Cases in America, recorded by Dr. Clymer, . . . 160 

Eemedies for the Destruction of the Parasite, ...... 162 

5. Description of the Filaria Medinensis, commonly called Guinea-worm 

or Dracunculus, . 163 

Essentially a Tropical Parasite, . 163 

Geographical Limits of its Occurrence, 163 

Prevalence amongst Soldiers at different Stations, ..... 163 

Duration of Illness caused by the Parasite, ...... 164 

Deaths resulting from Guinea-worm, 164 

Great Destruction of Tissue caused by the Parasite, 164 

Number of Guinea-worms sometimes found in the Human Body, . . 164 

Locality of the Body where it most frequently is found, .... 164 

Migratory Powers exhibited by the Guinea-worm before Extraction, . 165 

Structure of the Dracunculus, . . . . . . . . . 166 

i^orms of the Head and Tail-end of the Worm, 166 

Arrangement of the Intestine and Genital Organs, ..... 166 

Parthenogenis supposed to occur with Guinea-worms, .... 167 

Symptoms of Guinea-worm in the Human Body, 168 

Phases of its Existence oi" Forms of Life, ' . 168 

Period of the Tear when Dracunculus is most Prevalent, . . . 169 

Annual periodic Recurrence of the Parasite, ' . 169 

Periods of Annual progressive Increase of the Parasite, .... 169 
Fixed Latent Period of Residence — a period of Incubation — in the Human 

Body, 169 

Cases which fix the Period of Incubation, 169 

Geological Features of Locality and Soil where the Guinea-worm is 

Endemic 170 

History of the Guinea-worm and its Progeny unknown after it leaves 

the Body, 171 

Spontaneous Evolution or Expulsion of the Parasite, .... 171 

Vitality of the Guinea-worm in Water, ....... 172 

Examination of Water, Mud, and Tanks recommended, .... 172 

Description of the Tank-worm of India, . . ' 173 

Generation and Propagation of the Guinea-worm, 174 

Periods in its Natural History to be recognized, 174 

Contagion of Guinea-worm, 174 

Problems for Solution in th« History of this Parasite, . . . .' 175 

6. Description of the Pilaria Oculi — two kinds, 175 

7. Description of the Strongylus Bronchialis, 176 

8. Description of the Eustrongylus Gigas, 176 

9. Description of the SclerostomaDuodenalis, 176 

10. Description of the Oxyuris Vermicularis, 176 

Tkbatment of those Infested -with Round Worms,, .... 176 

Class B.— Stbkklmintha, or Solid Worms, 178 

11. Description of the Bothriooephalus Latus, 17S 

Regions where it Exists, 178 

Structure of the Parasite and its Ova 178 



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XXll CONTENTS OF VOLUME I. 

PAGE 

12. Description of the Bothriocephalus Cordatus, . . . . . . 179 

13. Description of Taenia Solium, 179 

Varieties of Tape-worms found in Man, 180 

Two only of Frequent Occurrence, 180 

Head of the Taenia Solium, 180 

Anatomy of the Tape- worm Segments, . 181 

Process of Expulsion of Ova, . 181 

Contraction of Proglottides 181 

Structure of Tape- worm Ova, . 183 

Development of Tape-worm Embryo, 185 

14. (Described at page 187.) 

15. Description of Taenia Mediocanellata, 185 

16 Description of T^nia Aeanthotrias, . 185 

17. Description of Taenia Flavopunctata, . . ... . . . 186 

18. Description of Taenia Nana, ■ . . . 186 

19. Description of Tajnia Lophosoma omitted. 

20. Description of Taenia EUiptica, 186 

Immature Tape-worms, Non-sexual, Cystic, or Vesicular Parasites, . 186 

Description of (14) Cysticercus of the Taenia Solium, .... 187 

Description of the (15a) Cysticercus ex Taenia Mediocanellata, . . 187 

21. Description of the Cysticercus of the Taenia Marginata, 188 

22. Description of the Echinococcus Hominis, ...... 188 

Hydatids, or Echinococcus Cysts, ......... 188 

Description of the Capsule and Embryo of the Echinococcus, . . . 189 

Clusters of Bchinococci Embryos, 189 

Description of the Head and Hooklets, 190 

Description and Nature of Acephalocysts, . 191 

Eelation between the Cystic and Cestoid Entozoa, ..... 191 

Nature of the Experiments made to determine this Relationship, . . 192 

Kuchenmeister's Experiments, 192 

Von Siebold's Experiments, . . . . . . . . . . 192 

Experiments of Leuckart and Cobbold, . 192 

Elementary Pacts regarding Entozoa, . . . . . ,' . .194 

Cyst-infected JBation-beef from the Punjaub, 194 

Drawing of Cysts from Eation-beef — Natural Size, 195 

Sources of Taenia Ova which Infect the Kation-beef, 196 

Prevalence of Watery Bag or Hydatid Cyst in Commissariat Cattle, . . 196 

Power of Preventing the Cyst-infection of Beef, ...... 197 

Customs in India favorable to Parasitism, . ■ 198 

Symptoms of the Presence of Tape-worm and Cystic Parasites, . . . 200 

Prevention and Treatment of Tape-worm, 200 

Prevention and Treatment of the Tape-worm and Vesicular Parasites, . 200 

Medical Treatment of Tape-worm and Vesicular Parasites, .... 201 

Medicinal Kemedies for Tape-worm 201 

Description of Fluke-like Parasites, 202 

The Eot in Sheep, 203 

Egg of Distoma and Opalina, 203 

Development of Distoma, 203 

Distoma found in the Human Body, 204 

Fasciola Hepatica, 205 

Distoma Crassum, 205 

Distoma Lancbolatum, 205 

Distoma Ophthalmobium, 205 

Distoma Hetbkophyes, 205 

BlLHARZlA HiEMATOBIA, 205 

Lesions from Bilharzia Haematobia, 205 

Ova and Embryo of Distoma Haematobia, 206 

'Tbtkastoma Eenalk, 206 

Hexathyridium Venarum, 206 

Hexathyridium Pinguicola, 207 

Symptoms of Distoma, . 207 

'Class C. — Accidental Parasites, ■ . 207 

Description of Accidental Parasites, .... ... 207 



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CONTENTS OP VOLUME I. XXlll 

PAGE 

Pbntastoma Constriotum in thb Lungs and Liver, . . • . 207 

Pbntastoma Denticulatum, _. 207 

Pbntastoma in the Human Liver, 207 

Description of the Pentastoma Constrictum and the Lesions it Produces, . 208 

Drawing of Parasite in situ in Portion of the Human Liver, . . . 208 

Drawings of tlie Parasite Removed from the Cysts, 208 

Drawings of Pentastoma Constrictum in Human Liver, from Specimens 

preserved in the Museum at Netley since 1854, ... . 211 

Oestrus Hominis, 211 

Anthomyia Canicularis, 211 

Pathology and Treatment of Bulama Boil, . 212 

Larva found in Bulama Boil, 212 

II. Ectozoa, . . . ... . . . . . . . . 212 

Description of Animals living upon the Skin and Hair, and the Lesions 

they Produce, 212 

Phthiriasis, 213 

Description of the Inguinal and Head Louse, ...... 213 

!Nit or Egg-capsule of the Louse glued to a Hair, 214 

Description of the Louse of the Eyebrows and Body Louse, . . . 214 

Description of the Distemper Louse, ....... 215 

Treatment of Lousiness, . 2l5 

Description of the Itch Spider, Sarcoptes Scabiei, 216 

Development of the Itch Spider, 218 

Description of Demodex Polliculorum, 219 

Description of Pulex Penetrans, Chigoe or Jigger, .... 219 

III. Entophyta and Epiphyta, 220 

Definition of Algae, Confervse, and Eungi, 220 

The Structural Elements of Eungi, 220 

Influence of Eungi on Disease, 222 

Transmission of Fungi from the Lower Animals, 223 

Pathognomonic Sign of Eungic Lesions, 223 

Non-identity of Parasitic Eungi, 225 

Di-morphism of Eungi, '226 

Multiple Eorms of Eructification of Eungi, 226 

Artificial Cultivation of Eungi 227 

Apparatus required for Cultural Experiments, 228 

Objects aimed at by the Cultivation of Eungi, 228 

Calculus and Concretion, 228 

Definition of Calculus and of Concretion, 228 

Pathology of Calculus and Concretions, 228 

Sources of Concretion, 229 

(1.) Concretions of Protein Substances, 229 

(2.) Concretions of Eats 229 

(8.) Concretions of Pigment, 230 

(4.) Concretions of TTric Acid and Urates, 230 

(5.) Concretions of Lime Salts, ■ • • .231 

(6.) Concretions of Ammonio-phosphate of Magnesia, 231 

Elementary Constituents of Concretions and Calculi, . - . . . . 232 

Malj-ormations, ^^^ 

Definition and Pathology of Malformations, 233 

Origin of Malformations, 233 

Classification of Deformities, ^34 

Elementary Eaots in "Teratology," ^<>4 

I. Malformations Kbsulting prom Incomplete Development or 

Growth ov Parts, 234 

(a.) Of the Body generally j°J' 

(6.) Of the Nervous System, j°^ 

(c.) Of the Organs of Special Sense, jo^ 

(d.) Of the Yascular System, ^o^ 

(e.) Of the Respiratory System, j°J> 

(/.) Of the Digestive System, ■^<*o 



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XXIV ■ CONTENTS OP VOLUME I. 

PAGE 

(g.) Of the Urinary System, 236 

(A.) Of the Male Organs of Generation, 236 

(i.) Of the Female Organs of Generation, 236 

II. Malfokmations Kesultinq prom Incomplete Coalescence of the 

Lateral Halves of Parts which should become Conjoined, 236 

(a.) On the Anterior Median Plane, 236 

[b.) On the Posterior Median Plane, .236 

III. Malformations Resulting from Coalescence of the IiAtekal 

Halves of Parts which should remain Distinct, . . . 237 

IV. Malformations Kesttltinq from the Extension of a Commissure be- 

tween THE Lateral Halves of Parts (causing Apparent Du- 
plication) 237 

V. Malformations Resulting from Repetition or Duplication of 

Parts in a Single Fcetus, 237 

VI. Malformations Resulting from the Coalescence of two Fcetuses, 

or of their Parts, 237 

VII. Congenital Displacements and Unusual Positions of Parts of the 

Fcetus, 237 

Examples of Double Monsters from One Germ, 238 

Functional Diseases 238 

Definition and Pathology of Functional Diseases, 238 

Fever, 240 

Definition and Pathology of Fever, 240 

Natural History of Fever generally, 240 

Galen's Definition of Fever, 241 

Two points to be determined where Fever is present, namely: (l.'j.The 
Amount of the Preternatural Heat; (2.) The Amount of the Tissue 

• Change, 241 

.The Sequence of Phenomena necessary to be known in Fever, . ... 241 

Pernicious System of Naming Fevers from Names of Places, . . . 241 

Defervescence in Fever and its Significance, 242 

Significance of the Terms " Crisis," " Lysis," and " Insensible Resolution," 242 

Usefulness of the Thermometer in Diagnosis, 242 

The Usefulness of the Thermometer at the Bedside in the Diagnosis of 

Pyrexia, 242 

Importance of determining the Thermometry of Disease, .... 243 

Methods of Recording the Fever-heat of the Body 243 

I. The Instruments, Methods, and Practical Rules for Observing and Record- 
ing the Temperature of the Human Body In Disease where Fever is 

present, 243 

Description of Clinical Thermometers, 244 

Diiferences in different Thermometers, 244 

Verification of Instruments at Kew or Greenwich Observatories necessary, 244 

Mode of Using the Clinical Thermometer, '...... 245 

Scales of Temperature Compared 246,247 

Blank Forms for Records of Temperature, Pulse, Respiration, and Ex- 
creta, 248, 249 

II. Fluctuations of Temperature within the Limits of Health, and the Cor- 
relation of the Animal Heat with the Pulse and Respiration, . . 250 

Development of Body-heat, 250 

Normal Temperature of the Human Body, ...... 260 

Periods of Minimum and Maximum Temperature, 250 

Circumstances which Influence Body-heat, 251 

Correlation of Pulse and Temperature, ....... 252 

Bodily Temperature of Children, 252 

III. Ranges of Temperature in Disease, 253 

Instances of Disease indicated by the Thermometer, .... 254 

Typical Ranges of Daily Temperature in certain Febrile Diseases, . . 266 

IV. Ranges of Temperature in Diseases where Fever is present, as related to the 

Amount of Excreta, 259 

Amount of Excreta Normal to the Body, 259 



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CONTENTS OP VOLUME I. XXV 



PAGE 



Relation of Excreta to Fever-heat, ■ . . . 262 

Eev. Samuel Haughton's Table for the Determination of Urea in 

Urine, 259, 260, 261 

" Getting the Turn " of a Fever . . . 263 

Table I. Abstract of Cases in which some of the Excretions are Increased 

in consequence of the Febrile State (Dr. Parkes), . . . 263 
" II. Cases in which there was Diminution of the Excretions (Dr. 

Parkes), .263 

" III. Table of Cases to show Local Lesions coincident with sudden Re- 
tention of the Excretions in Fever (Dr. Parkes), . . . 264 

Large Amounts of Urea Excreted, 265 

Retention of Water in the Febrile Body, 266 

Condition of the Urine in Fever, ' 266 

Condition of the Blood in Fever, . . . . ' 266 

Condition of the Pulmonary Excretion in the Febrile State, . . .266 

Condition of the Nervous System in the Febrile Statfi, 267 

Conditions which combine to Produce the Complex Phenomena of Fever, . 267 

CHAPTER IX. 

Types or Disease and their Tendency to Change, 269 

Definition of the Type or Form of a Disease, 269 

Results of Sanitary Science, 270 

Agencies Modifying the Types of Diseases, 272 

Change of Type in Continued Fever, . . 274 

Examples of Change of Type in Disease, 275. 

Active Sources of Degeneracy, 276 

Changes in the Medical Constitution, 278 

CHAPTER X. 

Modes by which Diseases terminate Fatally, 279 

Death from Decay of Life, by extreme Old Age, 279 

Death by Syncope and Asthenia, 280 

Death by Starvation, 281 

Death by Suffocation, or Apnoea, 281 

Death by Coma, . . 282 

CHAPTER XI. ' 

Principles which Dictate the Treatment of the Two Complex Moruid 

Processes — Fever and Inflammation, 283 

I. As regards Fevers or the Febrile State, 283 

Four Modes by which Fevers may naturally Terminate, . . . 283 

Combination of Measures necessary in the Treatment of the Febrile State, 283 

(1.) To Reduce Excessive Heat, 283 

Methods of Reducing the Heat of Fever, 284 

Rules for the Use of Alcohol in Fever 286 

(2.) To insure sufficient, but not excessive Excretion, and to Promote 

its Elimination in Fever, 286 

(3.) Restorative Agents in the Febrile State, 287 

II. As regards Inflammation, 288 

Nature of Antiphlogistic Treatment, 288 

Bloodletting, 289 

Immediate Effects of Loss of Blood, . . ' 290 

General Rules as a Guide to Bloodletting, 290 

Indications as to the Repetition of Bloodletting, 292 

Methods of Bloodletting, General and Local, 293 

Other Antiphlogistic Remedies, . . . . . . . . 294 

Use of Purgatives and Mercury, . . • . ■ 294 

Use of Iodide of Potassium, Antimony, and Opium, .... 295 

Use of Aconite, 295 

Use of Alkalies, 296 



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XXVI 



CONTENTS OF VOLUME I. 



PAKT II. 

PAGE 

Methodical Nosology — Systematic Medicine, or the Distinctions and 

Definitions, the Nomenclature and Classification of Diseases, . 297 

CHAPTER I. 

The Aim and Objects of Nosology, 297 

I. The Definition of Diseases 297 

Method of Defining Diseases, 298 

II. The Nomenclature of Diseases, 299 

Principles influencing the Names of Diseases, 299 

III. The Classification of Diseases, 300 

Principles of Classifying Diseases, . ' 301 

Systems of Classification of Diseases, . . . . . . • 301 

I. According to the Nature of the ascertained Causes of Disease, . 301 
II. According to the Pathological States or Conditions which attend 

Diseases, 301 

III. According to the Properties, Powers, or Functions of an Organ 

or System of Organs being Deranged, ..... 302 

IV. According as Diseases are Structural or Functional, . . . 302 
V. According to the Pathological Nature of the several Morbid Pro- 
cesses, . . . . . . . . ■ ■ • 302 

VI. According to the General Nature and Localization of the Morbid 

States, 303 

VII. According to the Principles of a purely Humoral Pathology, . 303 

VIII. According to the supposed Elements of Disease, .... 303 

IX. Dr. Stark's Classes of Diseases, . . . . . . . 303 

X. Classification of Dr. William Farr, 303 

No perfectly Philosophical or purely Natural Classification, . 304 

Conditions for a Philosophical Classification of Diseases, .... 304 

Present State and Aim of Nosology, _ . 305 

Origin of the New Nomenclature of Diseases by the College of Physicians 

of London, 306 

Plan of the New Nomenclature, 307 

Classification of Diseases by the College of Physicians of London, . . 307 

General Diseases (arranged into two Sections) and Local Diseases, . . 307 

Some Deficiencies of Practical Importance in the Nomenclature, . . 308 

The Future Prospects of Nosology, 309 

Provisional nature of the Nomenclature, 309 



CHAPTER IL 



Tabulae View OF "The Nomenclature of Diseases," drawn up. by a Joint 
Committee appointed by the Royal College of Physicians of London 



(1869). 

General Diseases (Sections A and B), 

Local Diseases, ..... 

Arrangement of Local Diseases, . 

Names of Diseases of the Nervous System, 
" Diseases of the Eye, 
"°" Diseases of the Ear, 
" Diseases of the Nose, 
" Diseases of the Circulatory System, 
" Diseases of the Absorbent System, 
" Diseases of the Ductless Glands, 
" Diseases of the Respiratory System, 
" Diseases of the Digestive System, 
" Diseases of the Urinary System, 
" Diseases of the Generative System, 
" Diseases of the Male Organs of Generation, 



310 
311 
311 
312 
312 
313 
313 
314 
314 
315 
316 
316 
318 
318 
818 



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CONTENTS OF VOLUME I. 



XXVll 



Names of Diseases of the Female Organs of Generation in, the Unimpreg' 
nated State, 

" Affections connected with Pregnancy, . 

" Affections connected with Parturition, . 

" Ji flections consequent on Parturition, . 

" Diseases of the Female Breast, .... 

" Diseases of the Male Mammilla, .... 

" Diseases of the Organs of Locomotion, . 

" Diseases of the Cellular Tissue, .... 

" Diseases of the Cutaneous Sj'stem, 

" Conditions not necessarily associated with General or 
eases, 



Poisons. . 
Injuries, . 
Local Injuries, 



Local Dis 



319 
320 
320 
320 
320 
821 
821 
822 
322 

323 
323 

324 
324 



PART III. 



Thb Natttrb 01' Diseases, Special Pathology, and Therapeutics, . . 826 

Objects of this Part, . .326 

Nature of the Diseases comprehended in the Sections A and B of the Gen- 
eral Diseases, 326 

Nature of the General Diseases comprehended in Section A, . . . 326 

Specific or Miasmatic Fevers, 326 

Malarious Fevers, 326 

Epidemic Diseases, 326 

Febrile Affections due to the introduction of Animal Matter in a State of 

Change, 826 

Nature of the General Diseases comprehended in Section B, . . . 326 

Constitutional Character of the Diseases, 326 

Method to be followed in the Chapters relative to the Pathology of General 

Diseases, 326 

Necessity fur Limiting and Fixing the Significance of the Terms " Mias- 
matic" and " Zymotic," 826 

Pathology of Zymotic Diseases, ......... 327 

Special Pathology, Special Diseases, 327 



CHAPTEE I. 



On the Nature of the Specific ok General Diseases commonly called 
Miasmatic, 



The Blood generally is more or less Changed in the General Diseases, 

Specific Poisons believed to Affect the Blood, 

Nature and origin of " Acute Specific " or " General Diseases," 

Contagious Nature of the Specific General Diseases, 

Nature of the " Specificity " of these General Diseases, 

Essential Characters of the Specific Diseases, 

Causes and Origin of Specific Diseases, 

Communication of Specific Diseases, . . . . 



327 

327 
828 
328 
328 
328 
328 
329 
332 



CHAPTER II. 



Theory of Specific Diseases, 



Differences in the Constituent Elements of the Diseases in Sections A and B, 
Additional Distinguishing Elements of Specific Diseases, . . . . 



832 



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XXVm CONTENTS OF VOLUME I. 



CHAPTER 111. 

PAGE 

The Physiological Modes in which Poisons Act Illustk-atbd by Anal- 
ogy WITH THB Specific or Miasmatic Feveks, . ... . . 334 

Action of Poisons Subject to Certain Laws, • . . 334 

(1.) Definite and Specific Action of Poisons, ....... 335 

(2.) Latency of Poisons, • 335 

(3.) Modifications of Action by Dose, Temperament, and Constitution, . 335 

Pbysiological Actions of Poisons, 336 

Constitutional Susceptibility of some Persons to Poisons, .... 336 

The Specific Action of Poisons which Produce Specific Disease, . . . 337 

Peculiarities in the Action of Poisons which Induce Specific Diseases, . . 339 

Multiplication of the Morbid Poison in the System, 340 

Protective Influence of one attack from other attaeljs 340 

Condition of the Blood in Specific Fevers, 341 

Deaths from Specific or Miasmatic Diseases, ....... 342 

Specific Disease Poisons, . . 343 

Endemic and Epidemic Influences, 344 

[Summary of Dr. MJurchison on the Pathology and Treatment of the Specific 

Pyrexiae in Miasmatic Fevers], . 344 



CHAPTER IV. 
On THE Nature of Malaria and Malarious Fevers, 



Forms of Malarious Fevers, 

Specific Effect of Malaria Poison on the Body, 
Persistent Pernicious Influence of Malaria Poison, 
Causes and Modes of Propagation of Malarious Fevers, 
Conditions for the Development of Malarious Fevers, . 
Varieties of the Malarious Poison, .... 



CHAPTER V. 

On the Nature of Endemic, Epidemic, and Pandemic Influences 

Vy^hence Endemic Influences Result, ...... 

Conditions through which Endemic Influences become Active, 
Question as to the Spontaneous Origin of Specific Miasmatic Diseases, 

Nature of Epidemic Influence, 

Epidemic Influence on Constitution, and Evidence of its Presence, 
Laws of Epidemic Influence, and Conditions under which it Acts-, 
Nature of Pandemic Influence, and Evidence of its Existence, . 
Nature of Animal Malaria, 



345 

345 
346 
847 
348 
349 
351 



352 

352 
352 
354 
355 
355 
356 
357 
357 



CHAPTER VI. 

Management, OF Epidemics; and on Proceedings which are advisable 
to be Taken in Places Attacked or Threatened by Epidemic 
Diseases, 359 

Possibility of Extinguishing or "Stamping out" the greater number of 

Epidemic Disea.ses, 359 ' 

Elementary Facts which Dictate the Steps to be talieu, .... 359 
Details of Proceedings advisable to be taken in Places Attacked or Threat- 
ened by Epidemic Diseases 359 

Rules for the Management of Epidemics, 359 

Rules for the Observation of Cases and the Government of Fever Hospitals, 362 

Processes of Disinfection, . . . 362 



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CONTENTS OF VOLUME I. XXIX 



CHAPTER VII. 

PAGE 

Pathology or the Enthetic, Implantbd, or iNootrLATED Kind of Specific 

OR General Diseases, 363 

Sources of the Poison of such Diseases, 363 

Definition of Poisoned Wounds, 363 

How the Poison is Eeceived into the System, 36.3 

How Germs of a Specific Kind become Directly Implanted, . . . 363 

Specific, Local, and Constitutional Effects of an Inoculated Morbid Poison, 364 

Example of the Action of a Poison from the Bite of a Bug, ... 364 

Example of the Action of the Poison of a Cobra di Capello, . . . 364 

Changes said to be Visible in the Blood-corpuscles subsequent to the Bite, . 365 

Pathological Action and Pathologj' of Specific Venoms, .... 365 

Nature of the Venom Secreted by Serpents, 365 

Deaths from Snake Bites in India are very numerous, . . . . . 366 

Names of the very Deadly Poison -snakes, 366 

Nature of the Venom secreted by Serpents — its General Appearance and 

Properties, 366 

Different Effects of the Venom according as it comes frqm Different Fami- 
lies of Snakes, 366 

Effects of the Venom of the Cobra (iV«ja), ... . . ... . 366 

Effects of the Venom of the Viper (Daboia), 366 

Effects of the Venom of the Rattlesnake (CVoteZirfce), 366 

Subsequent Effects of the Action of Serpent-venom 367 

Analysis of the Symptoms from Rattlesnake-venom, 367 

Chemical Analysis of Serpent-venom, . 368 

Digestion Destroys the Poisonous Properties of Serpent-venom, . . . 368 

Blood of an Animal killed by Snake- venom is itself Poisonous or Venomous, 368 

Morbid Anatomy of Brain, Blood, and Tissues, after death from Snake Bite, 369 

Effects of the Venom of the Cobra and Daboia Russellii, .... 369 

Effects of the Venom of the Bungarus, 369 

Question regarding " Antidotes" for the Venom of Snake Bites, . . . 370 

No Antidote for Serpent-venom, . . . . . . . . . 370 

Changes which the Absorbed Virus of Specific Diseases Undergo in the Hu- 
man Body, .... 371 

How Specific Disease-poisons differ from Venom, ...... 371 

Evidence of Increase of Virus of Disease-poisons within the Body, . . 371 

Evidence of Transformation of their Virus, 371 

Evidence of the Combination of Morbid Poisons wiWi some Blood Compo- 
nent, • . • . . .372 

Evidence of Separation oi: Excretion of Morbid Poisons, .... 372 

Rapid Effects of the Cadaveric Poison, 372 

Tardy Process of Incubation of some JPoisons, 372 

Varieties of Poisoned Wounds enumerated from the Nomenclature, . . 373 



CHAPTER VIII. 

On the Nature of the General Diseases of a Specific or Miasmatic 

Kind comprehended in Section, B, . . . . . • . . 373 

Nature of Constitutional Diseases, 373 

A Cachectic State or Bad Habit of Body, 373 

Course of Constitutional Diseases, 374 

Personal Peculiarities, Temperament, Diathesis, Hereditary Transmission, 

and Predisposition, 374 

Alternate Generations Suffer — Law of "Atavism," 374 

Blood Diseases and Constitutional Diseases 376 



• CHAPTER IX. 

Detailed Description of the General Diseases— Section A, . . . 376 

Small-Pox, ^^^ 

Definition and Pathology of Small-pox, 376 

Fever and Defined Course of Small-pox Eruption, 376 



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XXX CONTENTS OP VOLUME I. 

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Morbid Anatomy of Small-pox, 377 

Nature of the Small-pox Eruption, and Anatomical Structure of the Small- 
pox Pustule, 377 

Varieties and Symptoms of Small-pox, 379 

Symptoms of Natural Small-pox, 379 

Group A.— Unmodified or Natural Small-pox, . ' . . . . . 379 

Symptoms of Distinct Small-pox 380 

Course of the Disease, ........... 380 

Typical Range of Temperature in a Case of Natural Small-pox and Fever of 

Suppuration, ............ 381 

Description of Confluent Small-pox, .....;.. 383 

Symptoms of Inoculated Small-pox, 385 

Complications of Small-pox and Special Morbid Tendencies, . . . 386 

Pyogenic Fever after Small-pox, ... 386 

Sequelae of Small-pox, 387 

Course of Small-pox after Vaccination, ... 388 

Group B. — Small-pox after Vaccination — Varioloid, or Modified Small-pox, 388 
Definition of Small-pox after Vaccination (Modified Small-pox), . . . 388 
Symptoms, Course, and Modifications of Small-pox after Vaccination, . 388 
Typical Range of Temperature in a Case of Small-pox Modified by Vaccina- 
tion, 389 

Exhaustion of Susceptibility after an Attack of Small-pox, . . . 389 

Coexistence of Small-pox with other Morbid States, . . . . . 390 

Cause and Propagation of Small-pox, 390 

Causes which Predispose to Small-pox, . 391 

Prognosis and Causes of Death in Small-pox, . . . . . . 391 

Diagnosis of Small-pox 392 

Treatment of Small-pox, . . . . . . . . . : 393 

(1.) Therapeutic, Curative, or Sanative Treatment of Small-pox, . . 394 

Dietetic and General Medical Treatment of Small-pox, . . . 394 ■ 

Preventive Treatment of Small-pox 396 

(2.) The Prophylactic, Sanitary, or Preventive Treatment of Small-pox, 397 

Inoculation of Small-pox : Its Significance and Illegality, . . 398 

Cow-pox, 398 

Definition and Pathology of Cow-pox, . . 398 

Pathology and Symptoms of Cow-pox, 399 

Nature and History of Dr. Jenner's Discovery after 1780, .... 399 
Evidence that Animals (including Monkeys, Sheep, and Cattle) sutfer from 

Small-pox 399 

Evidence of Cases of Small-pox in Man communicating Variolous Disease 

to Cows, 400 

Direct Inoculation of Small-pox into the Cow from Man, .... 401 

Origin of all such Specific Poisons Unknown, 401 

Means adopted to Modify the Disease amongst Animals, .... 402 

Local Symptoms of Cow-pox in the Cow, ....... 404 

Nature of Primary Vaccine Lymph, . '.. : 405 

How to Procure Primary Vaccine Lymph direct from the Cow, . . . 405 

Useful Substitute for Liquid Lymph, 405 

Vaccination, 405 

Discovery and Nature of Vaccination by Dr. Jenner, 405 

Nature and Imperfection of the Vaccination Acts, . . . , . .' 406 

Present Position of our Knowledge regarding Vaccination, .... 407 

(1.) Nature and Evidence of the Protection conferred by Vaccination, . 407 

Influence for Good of Vaccination, . . ' 408 

Beneficial Influence of Perfect Vaccination, , . . . . 409 

(2.) How the Protective Influence of Vaccination has been Impaired, . 411 
No Deflnite Conclusion as to the Absolute Duration of Protection 

afforded by Vaccination, 411 

Vaccine Virus apt to Deteriorate from Bad Vaccination, .... 413 

Results of Spurious Vaccination, 414 

The Operation of Vaccination, 415 

Amendment of Vaccination Act of 1867 Proposed, 415 

Recommendation of the College of Physicians relative to Revacoination, . 415 

Signs of Successful Vaccination, ........... 417 

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CONTENTS OP VOLUME I. XXXI 

PAGE 

Signs of Successful Revaccination, . 418 

Characters of the Cicatrix after Vaccination, 418 

Number and Quality of Vaccination Marks, 419 

Four Degrees of Protection Indicated by Vaccination Marks, . . . 420 

Selection of Lymph for Vaccination, 420 

Ohickek-pox, . 421 

Definition and Pathology of Chicken-pox, 421 

Symptoms of Chicken-pox 422 

Diagnosis of Chicken-pox, 422 

Treatment of Chicken-pox, .......... 423 

Measles, 424 

Definition and Pathology of Measles, 424 

Characters of the Eruption of Measles, ........ 425 

Diagram representing the ilange of Temperature in a Case of Measles in 

which the Fever is Severe, 426 

Symptoms of Measles, 428 

Characteristics of Severe Forms of Measles, 429 

[Camp Measles in the American Armies] 429 

Diagnosis of Measles, 430 

Prognosis in Measles, . 430 

Causes of Measles, ............ 431 

Propagation of Measles by Direct Communication and Infection, . . 431 

Propagation of Measles, • .431 

Communication of Measles by Inoculation, 431 

Treatment of Measles, 432 

Scarlet FeviSr, — Syn., Scarlatina, 434 

Definition of Scarlet Fever, 434 

Significance of Synonyms in the Nomenclature of Scarlet Fever, . . 434 

Pathology and Morbid Anatomy of Scarlet Fever, ' . . . . . 434 

Three Forms of Eruption, 435 

Symptoms of Scarlet Fever, 436 

Varieties of Scarlet Fever, 436 

Albuminuria with Anasarca in Scarlet Fever, 436 

Symptoms of Simple Scarlet Fever, 437 

Typical Range of Temperature in a Case of Scarlet Fever, .... 439 

Dropsy after Scarlet Fever, 440 

Condition of the Urine in Scarlet Fever, 441 

Anginose Scarlet Fever, . . . . . • ■ ■ • • • 442 

Malignant Scarlet Fever, ■ • • 443 

Symptoms of Malignant Scarlet Fever, 443 

Special Lesions (or Localizations of them) in Scarlet Fever, . . . 445 

Diagnosis of Scarlet Fever 446 

Cause and Propagation of Scarlet Fever, 446 

Propagation of Scarlet Fever through Milk, 447 

Prognosis in Cases of Scarlet Fever, • ■ 448 

Treatment of Scarlet Fever, 448 

Preventive Treatment of Scarlet Fever, ...■..-. 462 

Hybrid of Measles and Scarlet Fever 454 

Definition of the Hybrid of Measles and Scarlet Fever 454 

Pathology of the Hybrid between Measles and Scarlet Fever, . . • *r- 

Symptoms of the Hybrid of Measles and Scarlet Fever, 4oo 

Symptoms of " Eotheln," 456 

Lesions Seen in Fatal Cases of " Eotheln," 4^' 

Diagnosis of "Eotheln," . . • • ■ ■ • • ■„„',: 
Table showing the most Prominently Distinguishing Characters oi Scarlet 

Fever, Rubeola, and Measles (Paterson), . . . . • ■ .J, 

Prognosis in Cases of "Rotheln," *°° 

Treatment of " Eotheln," ^'^^ 

T. ... 459 

Dengue, 

459 
Definition of Dengue, . . 

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XXxii ' CONTENTS OF VOLUME I. 

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Pathology and Symptoms of Dengue, 459 

Diagnosis and Treatment, . 4tiO 

Typhus Fkter, 460 

Definition of Typhus Fever, . . .460 

Varied Significance of the Term Typhus, 460 

Historical Notice of Typhus Fever, ......... 461 

[Immunity from Typhus ^fever in the American Armies during the "War . 

of the Kebellion], 462 

Causes of Disease in the British Army in the Order of their Greatest Influ- 
ence (Note) 462 

Phenomena and Symptoms of Typhus Fever, 463 

The Eruption of Typhus Fever, 464 

Body-temperature in Typhus Fever, 464 

Typical Range of Temperature i,n a Case of Typhus Fever, .... 467 

Correlation of Temperature and Pulse, , . . . 469 

Table showing Correlation of Pulse to Temperature, 470 

General Indications in Typhus 470 

Complications of Typhus Fever, 471 

Occurrence of Convulsions and Cerebral or Head Symptoms in Typhus Fever, 471 

Secondary Pulmonic Complications in Typhus Fever, . . . . . 473 

Gangrene of the Pulmonary Tissue in Typhus Fever, 474 

Secondary Cardiac Lesions in Cases of Typhus Fever, 474 

Prognosis in Cases of Typhus Fever, 474 

Cornbined Value of Temperature and Pulse in Cases of Typhus Fever, . 475 

Summary of Prognosis in Typhus, 476 

Combinations of Symptoms and Phenomena which are of extremely Unfa- 
vorable Import, 477 

Combinations of Symptoms and Phenomena which may be regarded as of 

Favorable Import, 477 

Modes of Fatal Termination, 477 

Condition of the Blood in Typhus Fever, . . _ 478 

Treatment of Typhus Fever, ^ . . . 478 

General Indications for Treatment, 479 

■ Special Indications for Treatment, 479 

Guide for the Administration of Alcoholic Stimulants in Typhus Fever, . 481 

Forms of Alcoholic Stimulants in Use, . 483 

Necessity of Careful Nursing, . . . . . . . . . 483 

Treatment of Headache and Delirium in Typhus, 483 

Origin and Propagation of Typhus Fever 486 

Communication of Typhus Fever by Fomites, . . . . ■ . . 486 

History of an Epidemic on Board the Egyptian Ship, " Soheah Geheld," at 

Liverpool in 1860, . . . .... . . . . .487 

Question as to the Origin of Typhus Fever de novo, ..... 488 

Summary of Evidence as to Contagious Nature of Typhus Fever, . . 488 

Conditions Essential for Propagation, 490 

Question as to the Period when a Typhus Patient ceases to Infect, . . 490 

Latent Period of Typhus Fever, . . . . ; . . . . 490 

Individual Susceptibility to Typhus Fever, . . . . . . . 491 

[Epidemic Cerebeo-Spinal Mbninottis, 492 

Definition of Epidemic Cerebro-spinal Meningitis, ..... 492 
The Name " Epidemic Cerebro-spinal Meningitis " an improper one for this 

Aifection, 492' 

History and Geographical Distribution of Epidemic Cerebro-spinal Mening- 
itis, 492 

Morbid Anatomy of Epidemic Cerebro-spinal Meningitis, .... 494 

Symptoms of Epidemic Cerebro-spinal Meningitis, 496 

Prognosis in Cases of Epidemic Cerebro-spinal Meningitis, .... 499 

Mortality in Epidemic Cerebro-spinal Meningitis, 499 

Diagnosis and Etiology in Epidemic Cerebro-spinal Meningitis, . . . 500 

Question as to the Contagiousness of Epidemic Cerebro-spinal Meningitis, . 501 

Nature of Epidemic Cerebro-spinal Meningitis, 502 

Treatment of Epidemic Cerebro-spinal Meningitis, 503 

Bibliography of Epidemic Cerebro-spinal Meningitis,] 505 



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CONTENTS OF VOLUME I. XXXUl 

PAOK 

BnTKRIC ]?ElrBR — St/ii., Ttphoid Pbyee, 506 

Definition of Enteric Fever, 506 

Pathology of Enteric Eever, 506 

Differences between Typhus and Enteric Eever, . ... . . . 507 

Various Beliefs Entertained regarding Enteric and Typhus Pever, . . 508 

Points of Differences between Enteric and Typhus Eever, .... 509 

Morbid Anatomy of the Lesions in Enteric Eever, with Special Keference to 

the Phenomena and Progress of the Disease, 510 

Anatomy of Special Lesions in Enteric Eever, 511 

Anatomical Eorms of the Intestinal Glands, ... . . . . .- 511 

Prevalence of Enteric Eever at Different Ages, 511 

Elimination of the New Material from Peyer's Glands during Enteric Eever, 513 

(1.) Elimination without Ulceration, ........ 513 

(2.) Elimination by Ulceration, 514 

Characters which distinguish the Ulcers of Enteric Eever from other 

Ulcers, 514 

(3.) Elimination of Enteric Growths of Peyer's Patches by Sphacelus, . 515 

(4.) Eeabsorption of Enteric Material, 516 

Catarrh and Atrophy of Intestine in Enteric Eever, 516 

Mesenteric Gland-lesion in Enteric Eever, 516 

Enlargement of the Spleen in Enteric Eever, 516 

Pulmonary (Secondary) Lesions in Enteric Eever, . . . ■ . . 516 

Tendency to Ulceration of Mucous Membrane in Enteric Eever", . . . 517 

Growth of Tubercle during Enteric Eever, 517 

Erysipelas, Phlebitis, and Parotitis during Enteric Eever, .... 518 
Microscopic Structure of the New Growth in Enteric Fever, . . .518 

Symptoms, Course, and Duration of Enteric Fever, . .. . . . 519 

Commencement of the Disease, 519 

Characters of the Stools and the Pulse, 519 

[Duration of Convalescence], 519 

Condition of the Mind in Severe Cases of Enteric Eever during Eecovery, . 521 

t Spinal Symptoms in Typhoid Fever, . . 521 

)escription of the Spinal Symptoms in the Famine Fever of 1848] , . . 522 

Eelapses of the Fever, 523 

The Cutaneous Eruption in Enteric Fever, ' '. . 524 

[A Miliary Eruption, of slight Diagnostic value, frequently occurs in Ty- 
phoid Fever, 525 

Typhoid Fever in Children], 525 

The Body-temperature during Enteric, Typhoid, or Intestinal Fever, . . 525 

Duration of Attack and Mode of Recovery in cases of Enteric Fever, . . 529 
Diagram Showing Eange of Body-temperature in a Severe and Prolonged 

Case of Enteric Eever, 530 

Eelapses in Enteric Fever, .531 

Condition of the Urine in Enteric Eever, 532 

I. As to Normal Constituents, 532 

IJ. As to Abnormal Constituents, 533 

Diagnosis in Cases of Enteric Fever, 533 

Tabular Statement of the Leading Diagnostic Points in Contrast, . . 534 
[Certain Phenomena met with in Typhoid Fever, from which a certain and 

timely Diagnosis can be made], 534 

Prognosis in Cases of Enteric Fever, _ . . ■ 535 

Circumstances under which Death may occur in Cases of Enteric Eever, . 586 



(1.) By Blood-poisoning ^^6 

■" ' By Implication of L_- „ „ - 

By Congestion of Important Organs, 536 



(2.) By Implication of Excretory Organs, 



536 
536 

(4.) By Heniorrhages, . " 536 

(5.) By the Exhaustion of Diarrhcea, 636 

(6.) By Peritonitis, l°° 

Origin and Propagation of Typhoid Eever, 537 

Elementary Facts regarding the Propagation of Enteric Fever, . _ . .638 
Preventive Measures, or Measures for Checking the Spread of Enteric Fever, 639 
Details of Procedure for Checking the Spread of Typhoid Fever, . . .540 
Question as to a Specific Poison and Origin of Enteric Fever, . . .640 
Pythogenetic Eever of Dr. Murchison, . . ••.■„■ ' .■ 
[Chief Determining Causes of Typhoid Fever m the United States Armies 

during the Eebellion], 642 

Treatment of Enteric or Typhoid Fever, oa*5- 

VOL. I. ^ 

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XXXIV CONTENTS OF VOLUME I. 

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Question of Checking the Diarrhoea, 545 

Good Eflfects of Calomel in Enteric Fever, 546 

Necessity of Attending to Diet in Oases of Enteric Fever, .... 549 

[Great Care and Vigilance necessary during Convalescence], . . . 550 

Kblapsing Fbtkr 550 

Definition of Relapsing Fever, 650 

Pathology and Historical Notice of Relapsing Fever, 550 

[History of Relapsing Fever in the United States], 552 

Phenomena of Relapsing Fever, 554 

The Primary Paroxysm in Relapsing Fever, 554 

The Crisis of Relapsing Fever, . 555 

Diagram of Temperature in a Case of Relapsing Fever (Herman), . . 556 

The Relapse or Recurrent Paroxysm in Cases of Relapsing Fever, . . 557 

Protracted Convalescence from Relapsing Fever, 557 

Tendency to the Occurrence of Sudden ]3eath, 557 

Duration of the Fever and Prolonged Duration of Convalescence, . . 558 

Sequelse of Relapsing Fever, 558 

Post-febrile Ophthalmitis (Mackenzie), 559 

Treatment of Relapsing Fever, 559 

Simple Coutiitubd Fever, 560 

Definition of 'Simple Continued Fever, 560 

Pathology of Simple Continued Fever, 560 

Reasons for Retaining this Name as the Name of a Disease, .... 560 

Anomalous Forms of Continued Fever, 561 

Febkioula, 562 

Definition of Fehricula, . . 562 

Pathology of Fehricula, 562 

Diagram of Typical Range of Temperature in a Case of Fehricula, . . 563 

Typical Range of Temperature in a Case of Protracted Fehricula, . . 563 

Diagnosis of Fehricula, . . 564 

Treatment of Fehricula, . . . 564 

.[Specific] Yellow Fever, . . . . 564 

Definition of Specific Yellow Fever, 564 

Pathology and Symptoms of Specific Yellow Fever, 564 

Necessity of Separating and Distinguishing the Specific from the Malarious 

Forms of .Yellow Fever, 565 

History of the " Eclair " Epidemic, 567 

- Incubation of Specific Yellow Fev,er, . 567 

Importation of Specific Yellow Fever, . . . . ' . . . . 568 

History of its Importation into St. Naziaire, 568 

Propagation of Specific Yellow Fever, . . . 569 

[Facts Favorable to the Doctrine of the Transmissibility and Portability of 

Yellow Fever] 571 

Symptoms of Specific Yellow Fever, 572 

Types, Groups, or Forms of Specific Yellow Fever, ... . . . 573 

» Several Types of Specific Yellow Fever, 573 

Condition of 'the Urine in Specific Yellow Fever, 574 

White and Black Vomit in Yellow Fever, 575 

Prognosis in Cases of Specific Yellow Fever, ...... 676 

Treatment of Specific Yellow Fever, 576 

Composition of Chlorodyne {Note), 578 

[Prevention of Yellow Fever], 579 

Plague, 580 

Definition of Plague, 580 

Pathology and History of Plague, 580 

Morbid Anatomy in Cases of Plague, 581 

Symptoms of Plague, 582 

Progress of the Bubo in Plague, 582 

Varieties of Carbuncle in Plague, 582 

Diagnosis in Cases of Plague, 683 



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CONTENTS OF VOLUME I. XXXV 

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Cause of Plagne, 683 

Modes of Propagation of Plague, 584 

Treatment of Plague, 584 

Quarantine, 585 

AavK—Syn., Intermittent Feter. 585 

Definition of Ague, 585 

Symptoms of Ague — Tha Paroxysm or Fit 585 

[Number of Cases of Intermittent Fever in tlie United States Armies dur- 
ing the first two years of the Civil "War (Note)], 685 

Varieties or Types of Intermittent Fever, 587 

[Congestive Form of Intermittent Fever], . . . . . . . 587 

Temperature in Cases of Intermittent Fever, 588 

Diagram of Typical Range ctf Body-temperature in Intermittent Fever of 

Quotidian Type, 588 

Diagram of Typical Kange of Body-heat in Intermittent Fever of Tertian 

Type, 589 

Condition of the Urine in Ague, 590 

Treatment of Intermittent Fever, . . • 591 

Remittent Fever, 594 

Definition of Remittent Fever, 594 

Symptoms of Remittent Fever, 594 

Varieties of Type of Remittent Fever, ........ 596 

[Prevalence of Remittent Fever In the Middle, Southern, and Western Re- 
gions of the United States, . . . . . . . . . 596 

Malignant Congestive or Pernicious Remittent Fever], .... 598 

Treatment of Remittent Fever, . • . . 599 

Professor "W. C. Maclean's Treatment of Remittent Fever [Note), . . 601 

[Chronic Malarial Toxaemia, 603 

Definition of Chronic Malarial Toxaemia, . 603 

Morbid Anatomy of Chronic Malarial ToxEemia, ...... 603 

Morphological Changes in the Bloofi in Malarial Fever, .... 604 

Treatment of Chronic Malarial Toxaamia], 606 

[Ttpho-Malarial Fever — Syn., Chickahomint Fever; American Fever, 607 

Definition of Typho-malarial Fever, 607 

History of Typho-malarial Fever, 607 

Symptoms of Typho-malarial Fever, 607 

Anatomical Character of Typho-malarial Fever, 608 

Treatment of Typho-malarial Fever], 608 

Malariotts Yellow Fbtek — Syn., Fbbkis Ictbrodbs Remittens, . . 608 

Definition of Malarious Yellow Fever, 608 

Pathology of Malarious Yellow Fever, 608 

Nature of the Soil in Relation to Malarious Yellow Fever, .... 610 

Malignant Cholera — Syn., Serous Cholera; Spasmodic Cholera; Asi- 
atic Cholera, - 611 

Definition of Malignant or Asiatic Cholera, 611 

Pathology of Malignant or Asiatic Cholera, , . .611 

Theories Explaning the Pathology of Malignant or Asiatic Cholera, . . 611 

Mr. Simon's Views regarding the Pathology of Malignant Cholera, . . 612 

Second, Third, Fourth, and Fifth Theories, 617 

Sixth Theory regarding the Pathology of Malignant Cholera, . . .618 
Seventh and Eighth Theories— those of Pettenkoffer and Macnamara — as to 

the Nature of Malignant Cholera, 618, 619 

Ninth Theory— Conclusions of Dr. Beasley, as expressed by Dr. Bryden, . 619 

Conclusions regarding the Several Theories, ■ . 620 

Quite as many False Facts as False Theories regarding Cholera, . . .620 
Earliest Knowledge of the Progress of Cholera due to the late Sir James 

Clark, .620 

Two points in which all the Theojies Agree, .620 



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XXXVl CONTENTS OF VOLUME I. 

PAOE 

Differences between the Epidemic of 1866 and Pormer Epidemics, . . 621 

Evidences of Importation or Transmission of tlie Disease, .... 621 

Infection of England in 1866 at many different parts, 622 

Occasional Circumstances which Eacilitate and give Energy to the Spread of 

Malignant Cholera, 624 

(1.) Meteorological Conditions, . . . 624 

. (2.) Local Causes, 627 

Views of Bayer, Barton, Carpenter, Pettenkofer, and Snow, regarding Local 

Influences, 628 

Impure "Water the Main Local Agent of Importance, 628 

Precise Conditions which Aggravate Epidemics of Malignant Cholera, as 

determined by Dr. Greenhow, 629 

Propagation of Cholera by Human Intercourse, ....'.. 630 

Communication of the Disease from Excreta, ...... 631 

Propagation through the Excreta of the Premonitory Diarrhcea, . . 633 

[Prevalence of Cholera in the United States Army in 1866, . . . 633 

Instances of the Portability of Cholera, 633 

The Organic Theory as a Cause of Epidemics, ...... 635 

Conclusions of Dr. Lionel S. Beale], 635 

Endemic Area and Epidemic Spread of Cholera, ...... 636 

Routes followed by Malignant Cholera, ....... 637 

Countries which have remained Eree from Cholera, ..... 639 

Dr. Macnamara's Characteristics of Malignant Cholera, .... 639 

Morbid Anatomy in Cases of Malignant Cholera, 641 

External Appearances, 641 

Condition of the Intestinal Canal, . 641 

Condition of the Visceral Organs, 641 

Condition of the Lungs, 642 

Dr. Johnson's Diagram of the State of the Heart and Lungs, . . . 642 

Post-mortem Appearances in Cases of Eeaction after Cholera, . . . 643 

Chemistry of the Blood in Asiatic Cholera 643 

Microscopy of the Body in Cholera, . . 646 

Question of Specific Fungi in Cholera Excreta, 646 

Hallier's, Thome's, Klob's, and Parke's Account of Eungi in Rice-water 

Stools of Cholera, 646 

Explanation of Engraved Plate, . . ■ 649 

Special Inquiry as to Fungi in Cholera, suggested by the Professors of the 

Army Medical School, to be carried out in India, and the Scheme pro- 
posed by them, 651 

Conclusions since arrived at regarding the so-called Cholera Fungi,* . . 653 
Chemical Changes Undergone by the Body in the Progress of Malignant 

Cholera, 654 

Question as to Epithelium in the Stools of Malignant Cholera, . . . 654 
Composition of Malignant Cholera, Intestinal Contents and Eice-water-like 

E'racuations, 665 

Symptoms and Various Forms of Cholera, 657 

Stages of Malignant Cholera, 657 

Period of Incubation of Cholera, 657 

Usual Course of the Disease as seen in this Country, 658 

Termination of Cases of Malignant Cholera, 659 

Hours at which Death takes place, . 660 

Typhoid Symptoms after Eeaction, 661 

The Blood and Urine in Malignant Cholera, 661 

Seven Stages of Cholera. distinguished by Thudichum, 662 

Body- temperature in Malignant Cholera, 662 

Duration of Malignant Cholera, . . - 664 

Relation of Vomiting and Purging to Algid Symptoms, .... 664 

Evidences of Reaction after Malignant Cholera, 665 

Circumstances Predisposing to Malignant Cholera, as well as those which 

present Resistance to the Attack, 666 

Prognosis in Cases of Malignant Cholera, 667 

Treatment of Malignant Cholera, 668 

Three Periods to be specially Provided for, 668 

Conditions to be attended to in the Management of Cases of Malignant 

Cholera, 668 

Circumstances Eegulating the Dose of Opium, 668 

Formula for Antispasmodic Pills, 668 



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CONTENTS OF VOLUME I. XXXVU 

PAGE 

Beneficial Influence of Opium, _. . . . 668 

Management of Large Bodies of Men in Armies, Factories, or Offices, with 

a view to the Prevention of Cholera, 669 

Elimination Treatment of Cholera by the Promotion of Purging and Vom- 
iting, 671 

Dr. George Johnson's Treatment of Malignant Cholera by Castor Oil, . 671 
Fallacies of the Theory of Elimination, on which Dr. Johnson's Treatment 

is Based, 672 

Dr. Macnamara's Experience as to Castor Oil, 673 

Aim of Treatment in the Algid Stage, 673 

Formula of Medicines to promote Reaction in Cholera and Diarrhoea, . . 673 

Question as to Use of Calomel in Reaction, . . ... . . 673 

Treatment during the Reaction Stage, by Dr. Andrew Clark, . . . 674 

[Mode of Treatment by Drs. Leclere and Barrant], 674 

The Kind of Cases Benefited by Calomel, 674 

Use of Water and Cold Compresses, 674 

Drinks recommended, . 674 

Injection of Medicated Fluid into the Veins, 675 

Stimulants not to be used, 675 

Prevention of Cholera, 676 

Use of Disinfecting Agents, 676 

[Cholera Mokbtts — Si/ra., Sporadic Cholbra; Simple Cholera; Cholera 

BiLiosA, 678 

Definition of Cholera Morbus, 678 

History of Cholera Morbus, 678 

Nature and Pathogeny of Cholera Morbus, 678 

Symptoms and Diagnosis of Cholera Morbus, 678 

Comparison of the Symptoms of Cholera Morbus with those produced by 

Irritant Poisons, 680 

Treatment of Cholera Morbus], 680 

[Cholera Infantitm — Syn., Summer Complaint; Infantile Cholera, . 680 

Definition of Cholera Infantum, 680 

History of Cholera Infantum, . ■ • 680 

Symptoms of Cholera Infantum, 681 

Causes and Nature of Cholera Infantum 682 

Effective Causes, — Age, High Temperature, Humidity, and Malnutrition, . 682 

Malnutrition due to Several Sources, ' 682 

The Necroscopic Characters of Cholera Infantum, 683 

Treatment of Cholera Infantum], 683 

Diphtheria,, ^^^ 

Definition of Diphtheria, 685 

Historical Notice of Diphtheria, 685 

Pathology and Morbid Anatomy of Diphtheria, 686 

Condition of Urine in Diphtheria, 688 

Albumen in the Urine of Diphtheria, 688 

Phenomena and Symptoms of Diphtheria, 690 

Varieties of Diphtheria, as Grouped by Sir William Jenner, . . " °°Y 

Diagnosis in Cases of Diphtheria, 691 

Prognosis in Cases of Diphtheria, 69^ 

Sequels after Cases of Diphtheria, 69- 

Peculiar Paralysis Subsequent to Diphtheria, 69^ 

Propagation of Diphtheria, 69d 

Treatment of Diphtheria, °^* 

Topical Applications, ^°° 

Question of Tracheotomy in Diphtheria, ■ oao 

Importance of Feeding the Patient, o^" 

.... 696 

HOOPINO-COTTGH, 

Definition of Hooping-cough, • „ • . ■ ■ ?q? 

Pathology and Morbid Anatomy of Hooping-cough, . , . . • • bab 

^STei:'c'^Z^^^:A a ..Fit" or .■ Paroxysm'' of Hooping-cough; 698 

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XXXVIU CONTENTS OF VOLUMK I. 

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Complications in Cases of Hooping-cough, 699 

Diagnosis in Caste of Hooping-cough, 700 

Cause of Hooping-cough and Modes of Propagation, 700 

Period of Latency of Hooping-cough, 701 

Prognosis in Cases of Hooping-cough, 701 

Ages of Fatal Cases, . . . 701 

Treatment of Hooping-cough, 701 

Dietetic and General Management of Cases of Hooping-cough, . . . 704 

Mumps, 704 

I Definition of Mumps, 704 

Pathology of Mumps, 704 

A symptomatic Parotitis as distinguished from the Idiopathic Parotitis of 

Mumps, .704 

Spread of the Disease by Contagion, 704 

Symptoms of Mumps, . . . . . . . . . . • 705 

Treatment of' Mumps, 705 

Influenza, . . . 705 

Definition of Influenza, ........... 705. 

Historical Notice of Influenza, 706 

Pathology of Influenza, 706 

Symptoms, Course, and Complications of Influenza, 707 

Special Pulmonary Complications, 707 

Causes and Modes of Propagation of Influenza, ...... 709 

Susceptibility to Influenza exhausted to a certain extent, not absolutely, . 709 

Prognosis in Cases of Influenza, 709 

Treatment of Influenza, 709 

Glanders, 711 

Definition of Glanders, 711 

Pathology of Glanders, 711 

Morbid Anatomy in Cases of Glanders, ........ 712 

Symptoms of Glanders, "^713 

Special Eruption in Cases of Glanders, 713 

Acute and Chronic Glanders or Farcy, 714 

Causes of Glanders, ........... 714 

Transmission of Glanders from the Horse to Man, 7f5 

Inoculation of the Poison of Glanders, 715 

Period of Latency in Cases of Glanders, 715 

Prognosis in Cases of Glanders, ......... 716 

Diagnosis in Cases of Glanders, ......... 716 

Treatment of Glanders, * . . 716 

Preventive Treatment of Glanders, 716 

Farcy, 717 

Definition of Farcy, 717 

Pathology of Farcy, , 717 

Morbid Anatomy — "Farcy Buds" and "Farcy Buttons," . . . . 717 

Equinia Mitis, 71S 

Definition of Equinia Mitis, . . . ' 718 

Pathology of Equinia Mitis, 718 

Affection known as " Grease " in Horses, 718 

Morbid Anatomy — "Grapes" and other Lesions Produced by " Grease," . 718 

Symptoms of Equinia Mitis, . . . 718 

Treatment of Equinia Mitis, 718 

Maligkant Pustule (Vesicle), 718 

Definition of Malignant Pustule, 718 

Pathology and Historical ZS'otice of Malignant Pustule, .... 719 

Propagation of Malignant Pustule, 720 

[Malignant Pustule occasionally of Spontaneous Origin, .... 720 



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CONTENTS OF VOLUME I. XXXIX 

PAGE 

Diversity of Opinion regarding ttie Kisk of Eating the Flesh of Animals 

affected with Malignant Pustule (iVo^e)], 720 

Phenomena and Symptoms of Malignant Pustule, ..... 720 

[Malignant CEdeilia of the Eyelids, 721 

Anatomical Characters of Malignant Pustule], 721 

Treatment of Malignant Pustule, 722 

Phagedena, 722 

Definition of Phagedena, 722 

Pathology of Phagedena, 722 

Treatment of Phagedena, 723 

SLOTjeHTNG Phagedena, . . 723 

Definition of Sloughing Phagedena, 723 

Pathology of Sloughing Phagedena, 723 

Hospital Gangrene, 723 

Definition of Hospital Gangrene, 723 

Pathology of Hospital Gangrene, 723 

Cases Prone to Hospital Gangrene, . 723 

Ektsipelas, 724 

Definition of Erysipelas, 724 

Pathology of Erysipelas, 724 

Lesions in Erysipelas not limited to the Skin, ...... 724 

Probable Origin and Seat of Erysipelas in the Absorbents, .... 725 

Suppurative Process and Effusion in Erysipelas, ...... 725 

Morbid Anatomy in Cases of Erysipelas, 726 

Symptoms of Erysipelas, 726 

Diagnosis in Cases of Erysipelas, 727 

Typical Range of Body-temperature in Cases of Erj'sijielas of the Pace, . 727 

Local Symptoms of Erysipelas, 728 

Phlegmonous and Gangrenous Erysipelas, ....... 729 

Cause of Erysipelas, ........... 730 

Internal Lesions Associated with Erysipelas, ...... 780 

Propagation of Erysipelas by Inoculation and Pomites, .... 730 

Identity with some Forms of Puerperal Fever, 731 

Period of Latency of Erysipelas, 731 

Prognosis in Cases of Erysipelas, ......... 731 

Treatment of Erysipelas, 732 

Local Applications in Cases of Erysipelas, ........ 733 

Pyemia, 734 

Definition of Pyaemia, 734 

Pathology of Pysemia, 734 

Pyogenic Fever, 735 

Difference of Pyogenic Fever from True Pysemia, 736 

Metastatioal Dyscrasiae and their Nature, 736. 

Literal Meaning of Pyemia, 736 

Composition of Pus, 737 

Eesults of the Decomposition of Pus, 737 

Pyeemia a Collective Name for several different Lesions, 738 

Morbid Anatomy — Secondary or Metastatic Abscesses, . ' . . 740' 

Difference of Pysemic Abscesses from Ordinary Purulent Collections, . . 740' 

Symptoms of Pysemia, 741 

Body-temperature in Cases of Pysemia, 742: 

Diagram of Body-temperature in a Case of Pysemia (Binger), . . . 743 

Diagnosis in Cases of Pysemia, 744 

Prognosis in Cases of Pysemia, 744 

Treatment of Pysemia, 745. 

[Chronic PTiEMiA, • • ■ '^^^' 

Description of Chronic Pysemia, 745- 



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xl CONTENTS OF VOLUME I. 

PAGE 

Prognosis in Chronic Pyemia, 746 

Treatment of Chronic Pycemia], 746 

Puerperal Peter, 746 

Definition of Puerperal Fever, 746 

Pathology of Puerperal Pever, 746 

Alliance between Puerperal Fever and Erysipelas, 747 

Origin of Cases of Puerperal Fever, 747 

Dr. Hicks's Experience as to the Origin of Puerperal Fever, . . . 747 

■ Morbid Anatomy in Gases of Puerperal Fever, 748 

Symptoms of Puerperal Fever, 748 

Treatment of Puerperal Fever, 749 

Puerperal Ephemera or Weed, 750 

Definition of Puerperal Ephemera, ........ 750 

Pathology of Puerperal Ephemera, 750 

Symptoms of Puerperal Ephemera, 750 

Treatment of Puerperal Ephemera, 750 

OHAPTEE X. 

Pathological Summary reqarding the Nature of the General Dis- 
eases described under Section A, ...... . 750 

Groups of those Diseases according to Natural Alliances, .... 750 

Nature of Contagion and Infection, 751 

Nature of the Poison-causing Particles, 751 

Form is that of a Minute Germ or Granule, 751 

Distinction to be made between Poison-reproducing General Diseases and 

those which do not Keproduce the Poison, ...... 752 

CHAPTEK XI. 

Detailed Description of the General Diseases comprehended in Sec- 
tion B, 752 

Explanation of the Term Diathesis, . . 752 

Acute Rheumatism — Syn., Ehbumatic Fever, 752 

Definition of Acute Eheumatism, . . . 752 

Pathology of Acute Eheumatism, 753 

Circumstances which point to the Constitutional Origin of Eheumatism, . 753 

Parts affected in Acute Eheumatism, . 754 

Eesults of Acute Eheumatism, 755 

Heart Affection in Acute Eheumatism, 756 

Lesions from which the Heart is apt to suffer in Acute Eheumatism, . . 756 

Complex Lesions in Acute Eheumatism, 757 

Morbid Anatomy in Cases of Acute Eheumatism, 758 

Symptoms of Acute Eheumatism, 758 

The Urine in Cases of Acute Eheumatism, 759 

Body Temperature in Acute Eheumatism in a Severe Case, .... 759 
Diagram of the Typical Eange of Body-temperature in a Case of Acute Eheu- 
matism affecting many Joints (Wunderlich), 762 

Symptoms of Heart Complications in Eheumatism, 764 

Pain and " Pains" in Chronic Eheumatism in relation to " Malingering," . 765 

Diagnosis in Oases of Acute Eheumatism, 765 

Prognosis in Cases of Acute Eheumatism, 765 

Indications of Acute Eheumatism from Urinary Excreta, .... 766 

Causes of Acute Eheumatism, 766 

Treatment of Acute Eheumatism 767 

Aim and Object of Purgative Eemedies, 769 

Composition of the Eemedy known as the "OAeJsea Pensioner," . . . 770 

Neutralizing and Eliminative Methods of Cure, 773 

[Constant Galvanic Current in Chronic Eheumatism] 774 



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CONTENTS 0¥ VOLUME I. xli 

PAGE 

GONOREHCBAL EhBUMATISM, 774 

Definition of Gonorrhoeal Kheumatism 774 

Pathology of Gonorrhoea! Rheumatism, 774 

Theories regarding the Nature of Gonorrhceal Eheumatism, . . . 774 

Symptoms of Gonorrhceal Eheumatism, 775 

Treatment of Gonorrhceal Eheumatism, 776 

Stnotial Ehetjmatism, 776 

Definition of Synovial Eheumatism, 776 

Pathology of Synovial Eheumatism, 776 

Treatment of Synovial Eheumatism, 776 

Muscular Eheumatism, 777 

Definition of Muscular Eheumatism, 777 

Pathology of Muscular Eheumatism, 777 

Lumbago, 777 

Stifi-neck and other Forms of Muscular Eheumatism, 777 

Treatment of Muscular Eheumatism, 777 

Chronic Eheumatism, 777 

Definition of Chronic Eheumatism, 777 

Pathology and Symptoms of Chronic Eheumatism, 777 

Treatment of Chronic Eheumatism, 778 

Acute Gout, 779 

Definition of Acute Gout, 779 

Pathology of Acute Gout, 779 

Constitutional Origin of Gout, 779 

Theories regarding Exo.ess of Uric Acid in the Blood, 781 

Niemeyer's Theory regarding Gout, 781 

Natural History of Acute Gout, 782 

Causes of Acute Gout, 783 

Most important Factors in the Production of Gout, 783 

Varieties of Gout, 784 

Morbid Anatomy in Cases of Acute Gout, 784 

Urateof Soda(Fig. 84) (Wbdl), 784 

Symptoms of Gout 784 

Diagnosis of Gout, '786 

Prognosis in Cases of Acute Gout,. 787 

Treatment in Cases of Acute Gout, 787 

Chronic Gout, ''^90 

Definition of Chronic Gout, 790 

Pathology and Symptoms of Chronic Gout, 790 

Nature and Course of Eetrocedent Gout, 791 

Gout as Afi'ecting Internal Organs, 791 

Treatment of Chronic Gout, 792 

Mineral Springs which Exercise the most Favorable Infiuenoe on Gout, . 792 

Eules regarding the Use of such Springs, 792 

Properties and Constituent Elements of the Mineral Waters at the Differ- 
ent Springs, '^92 

Gouty Synovitis, '^96 

Definition of Gouty Synovitis, 796 

Pathology of Gouty Synovitis, 796 

Treatment of Gouty Synovitis, 796 

Chronic OsTEO-ARTHRiTis—zSt/ra., Chronic Eheumatic Arthritis, . . 796 

Definition of Chronic Osteo-arthritis, 796 

Pathology and Symptoms of Chronic Osteo-arthritis, . . . . . 79b 
Table Exhibiting the Differential Diagnosis of Gout, Eheumatism, and 

Chronic Osteo-arthritis (Dr. Garrod), 797 

Treatment of Chronic Osteo-arthritis, '^o 



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xlii CONTENTS OF VOLUME.!. 

PAGE 

Syphilis, 799 

Definition of Syphilis, 799 

Pathology and Morbid Anatomy of Syphilis, / 799 

History of Syphilis in Soldiers, 800 

Keduotion of Venereal Diseases in the Army, ■ 801 

Special Eeturns called for in the Army regarding this Disease, . . . 802 

Nomenclature of Syphilis, 802 

Professor Longmore's Directions for Drawing up a History of Cases of 

Syphilis, 803 

Conclusions regarding the Venereal Poisons, 804 

How the Vaccine Virus may Carry Syphilis, ...... 805 

Nature of the Syphilitic Poison, 805 

Anatomy of the Induration of a Syphilitic Sore, 805 

Characters of the Venereal Sores, and especially of the " Infecting Sores," 806 

History of the Identification of the several Venereal Poisons, . . . 806 

Several Venereal Infections, .......... 806 

Porms of Syphilitic or Infecting Sores, . . . 808 

Clinical Characters of the Syphilitic Sore, . . . . . . . 810 

Characters of True Syphilis and Pseudo-syphilis Contrasted, . . . 810 

Period of Incubation of Sj'philis, 810 

Contamination of the System and General Course of Syphilis, . . . 811 

State of the Blood in Syphilis, 811 

Fever of Syphilis, 811 

Order of Evolution of Syphilitic Lesions, .812 

Succession of Phenomena in Syphilis, ........ 813 

Characteristics of Specific Induration, ........ 814 

Tabular Order of Events regarding the ^ecific Lesions of Syphilis, . . 815 

Cutaneous Affections in Syphilis, 815 

The Early Affections of the Pauces, 815 

Second Attacks of Syphilis, 815 

The Soft or Suppurating Chancre, 816. 

Vehicles or Media by which the Specific Infecting Virus may be Inoculated, 817 
Herpes Preputialis — its Characters, and how the Lesion is to be distin- 
guished from Syphilis, 817 

Modes of Syphilitic Contamination, 818 

Morbid Anatomy of the Secondary Lesions of Syphilis and of the Local 

Growths in the Internal Viscera 818 

Gummata the Basis of the Characteristic Lesions of Syphilis, . . . 819 

' Development and Course of the Syphilitic Node, or Gummy Tumor, . . 820 

(a.) In the Skin, 820 

(b.) Syphilitic Lesion of Mucous Membrane, ...... 821 

(c.) Affections of the Nails, . . . . . . . . . 822 

(d.) The Syphilitic Lesions of the Testicles, 822 

(e.) In the Substance of the Heart, . . ' 822 

(f.) In the Bones, 823 

(g.^ In the Brain and Nervous System, 825 

(h.) In the Lungs, 826 

(i.) In the Liver 826 

(k.) Lesions of the Tongue, 827 

Hints for the Investigation and Description of Syphilitic Ulcers, . . 827 

Syphilization : its History and Nature, 828 

Description of the Process of Syphilization, 829 

Treatment of Syphilis, . ,, . 829 

Question of Mercury in Syphilis, . 830 

Porms of Syphilis for which Mercury is Unsuitable, 832 

[Beneficial Effects of Mercury when Properly Administered], . . . 833 

Preventive Treatment of Syphilis, ' . . 836 

[Hebbditary Syphilis 837 

Pathology of Hereditary Syphilis, 837 

Syphilis may affect the Foetus at an Early Period, 838 

Coryza the iSarliest and most Striking Symptom of Inherited Syphilis, . 838 

Diagnosis of Inherited Syphilis, 839 

Appearance of the Teeth in Hereditary Syphilis, . . , . . . 839 
Several Affections of the Eye of Interest in the History of Hereditary 

■ Syphilis], 840 



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Cancbe — Sj/ra., Malignant Disease 841 

Definition of Cancer, 841 

Pathology of Cancer, 841 

Constitutional Origin of Cancer, . . . . . . . . . 842 

[Opinion as to the Local Origin of Cancer independently of a Constitutional 

Cause], 842 

Very little known of the Conditions giving rise to Cancers, .... 845 

Normal Course of Cancerous Tumors, 845 

Idea of Cancers being due to Entozoa, ........ 845 

Composition of the Local Exudations of Cancer-growths, .... 845 

Characters of the Cancer-cell, 846 

Practical Questions to be Solved with reference to Growths supposed to be 

Cancers, 846 

Malignant Tumors indicated by certain Characters Described, . . . 847 

(a.) Structure, 847 

(b.) Grouping, 847 

(c.) Infiltration, 847 

(d.) Tendency to Ulcerate, 847 

(e.) Progressive Growth towards Death, 847 

Microscopic Characters of Cancer-growths, ....... 848 

Microscopic Distinction of Cancer-elements, . 848 

Mode of Extension of Cancer-growths, . 849 

Varieties of Cancers described under various names, 850 

(a.) Constituents and Definition of Scirrhus or Hard Cancer, and figure 

showing the Cancer-cells of Scirrhus, ...... 851 

(b.) Elements of Medullary Cancer and Definition of it, . . . 852 

Constituents related to Firmness and Softness, ... . . . 852 

Process of Softening, 854 

Characters of Epithelial Cancer or Cancroid Epithelioma, . . . 855 

Sites of Epithelioma, 855 

Question of Classifying Epithelioma with Cancers, .... 855 

Essential Characteristic Elements of Melanotic Cancer, . . . 856 

Characters of Melanotic Cancer or Melanosis, 856 

fungus Hsematodes, 856 

Woodcut showing the varied Elements of Epithelial Cancer, . . . 857 

Osteoid Cancer and Villous Cancer, 858 

Elements of Melanotic Cancer, 858 

Causes of Cancer, 858 

Theories or Hypothesis regarding Causes of Cancer, . . . . . 858 

Diagnosis of Cancer, 859 

Prognosis in Cases of Cancer, 859 

Treatment of Cancer, . . . . ' 859 

Colloid — Syn., Colloid Canckr, Alveolar Cancbk, 861 ' 

Definition of Colloid, 861 

Pathology of Colloid, 861 

Doubtful Affinity with Cancer, . 861 

[Eorm of Colloid which belongs to the True Cancer Group, Anatomically 

and Clinically], • • • ®^^ 

LuPffS, . . 862 

Definition of Lupus, 862 

Pathology of Lupus, . 862 

Symptoms of Lupus, 863 

Diagnosis of Lupus, °63 

Prognosis in Cases of Lupus, 863 

Treatment of Lupus, 863 

EoDENT Ulcer, 865 

Definition of Rodent Ulcer, 865 

Pathology of Eodent Ulcer, 865 

True Leprosy— Syre., Elephantiasis GRiECORirM, 865 

Definition of True Leprosy, 865 



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xliv CONTENTS OF VOLUME I. 

PAGE 

Pathology of True Leprosy, . 865 

Keport by the College of Physicians regarding True Leprosy, . . . 865 

Hereditary Nature of True Leprosy, 865 

Leprosy now Unknown in this Country, 865 

Prevalence of Leprosy in this Country during the Middle Ages, . . . 866 

Present Geographical Distribution of True Leprosy, 867 

Porms of True Leprosy described, 868 

Acute and Chronic, Tuberculous and Ansesthetie, 868 

Morbid Anatomy in Cases of True Leprosy, 869 

A. Analyses of Venous Blood in Norwegian Tuberculous Elephantiasis, by 

Danielssen and Boeck, . . . 870 

B. Analyses of Venous Blood in Anesthetic Elephantiasis, by Danielssen, . 871 

Minute Anatomy of the Infiltration of True Leprosy, 871 

Chemical Analysis of the Exudation, 871 

Symptoms of True Leprosy, 871 

Summaryof Symptoms in the Two Forms of Leprosy, 872 

Duration of True Leprosy, "873 

Causes of True Leprosy, 873 

Diagnosis in Cases of True Leprosy, 874 

Prognosis in Cases of True Leprosyi 874 

Treatment of True Leprosy, 874 

Scrofula, 875 

Definition of Scrofula, • . 875 

Pathology of Scrofula, 875 

Specific Porms of Scrofulous Disease, 875 

Growth of the Peculiar Substance named "Tubercle," 875 

Constitutional Conditions associated with Scrofulous Disease, . . . 875 

Original Meaning of the terms "Phthisis," " Consumption," . . . 875 

Predisposition to Scrofulous Growths, . . 876 

Nature of the Constitutional State leading to the Development of Scrofula, . 876 

Strumous Dyspepsia, 878 

Diathesis expressive of the Latent Existence of Scrofula, . . . . 878 

Morbid Anatomy of Tubercle, 879 

Opinions entertained regarding the Nature of Tubercle, . . . . . 879 

Definition of Tuberculization, 880 

Eelation between Tuberculosis and Serofulosis, 880 

Porms and Conditions under which Tubercle appears, 880 

Gray and Yellow Tubercle — their Structure and Eelations, . . . . 880 

Microscopic Structure of Tubercle, 880 

Patty Degeneration of Tubercle, . •. 882 

Basis of Tubercle-structure, 882 

Development of Tubercle from Connective Tissue, 882 

Tubercle in Earliest Stage of Growth, . . . . . . . .883 

Cheesy Metamorphosis of Tubercle 883 

Retrograde Changes in Tubercle, 884 

Cretification — Calcification of Tubercle, 884 

Chemical Composition of Tubercle, 884 

Nomenclature of Tubercle, . . 885 

Seat of Scrofulous Inflammation in Peritoneum and Mucous Membrane, . 885 

Forms of Tubercle Ulceration, 885 

Inflammation of Tuljercle, 885 

Eelation of Bloodvessels to Tubercle and Cancer, ■ . 885 

Distinction between Tubercle and Cancer, 886 

Softening of Tubercle not constant, 886 

Healing of Local Lesions in Scrofula, 886 

Spontaneous Cure of Tubercle Lesions, 886 

Symptoms of Scrofula or of the Cachexia which precedes and accompanies 

the Growth of Tubercle, ' . 886 

The Dyspepsia of Tuberculosis, . 887 

Cases of Scrofula referable to Impaired Assimilation of Nutrition Processes, 887 

Strumous Dyspepsia of Tweedy Todd, i . . . 887 

Conclusions regarding Dyspepsia in Phthisis, . ... . , 887 

Characters of the Scrofulous Organization by Miller and Canstatt, . . 888 

Scrofulous Constitution of Children 889 

Type of Inflammation in Scrofulous Subjects, 889 

Duration of the Phthisis Pulmonalis of Scrofula, . . . . . . 889 



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CONTENTS OF VOLUME I. xlv 

PAGE 

Causes of Scrofula, 889 

Development during Infancy, 890 

Age in relation to Scrofula 890 

Deficient Ventilation and Abeyance of Normal Exercise, .... 890 

Influence of Occupations in causing Scrofula, 891 

Moisture and Damp as a cause of Scrofula, 892 

■ Morbid States of the Parent, a cause of Scrofula in Children, . . . 892 

Hereditary Prevalence of Scrofula, 892 

Manifestation of Scrofulous Constitution in Children, 893 

Influence of Eace in the Production of Phthisis, 893 

Influence of Depressing Passions in producing Phthisis, .... 893 

Is a Predisposition to Scrofula demonstrable anatomically or otherwise? . 894 

Assemblage of Phenomena characteristic of Scrofula, 694 

Great Care necessary in Physical Training, 894 

Average Weight of Pull-grown Men at.twenty-five years of age, . . 894 

Average Height of a Growing Lad at eighteen years of age, . . . 894 
Correlation of Age, Weight and Height in the Growth of the Human Body, 

from eighteen to thirty years of age, 895 

Correlation of Age, Stature, and Weight of Boys from nine to nineteen years 

of age 896 

Correlation of Height and Circumference of Chest in 1270 Young Persons, . 896 

Tear of greatest Increase in Stature, 896 

Tear of greatest Increase in Weight, 896 

Certain Individual Peculiarities suspicious, 896 

Vital Capacity of Chest, 896 

Indications of Functional Incapacity, 897 

Relation of Anaemia to Scrofula, 897 

Physical Training — Use of the Lungs, 897 

Evil Effects of Vitiated Air and Over-exertion, 898 

Progressive Atrophy indicative of Scrofula, 899 

Necessity for Weighing Men to determine Eatio to Age and Height, so as 

to furnish a Standard for determining Progressive Loss of Weight, . 899 

Progressive Eeduction in Weight in Phthisis, 899 

General Treatment of the Scrofulous Cachexia, 899 

Beneficial Influence of Cod-liver Oil, ........ 900 

Modes of its Administration, 901 

Its Immediate Action upon the Blood, 901 

Influenceof Animal Pats and Oils, . . . . - P02 

Question of Bloodletting in the Inflammations of Tubercular Exudations, . 902 

Tonic Treatment of Scrofula, 903 

Details of Hygienic Measures regarding Prevention and Management of 
Scrofula, . ■ . . . .903 

ElCKETS 905 

Definition of Eickets, 905 

Pathology of Rickets, 905 

Changes in the Bones in Eickets, 905 

Symptoms of Eickets, 905 

Treatment of Eickets, 907 

Cretinism, 908 

Definition of Cretinism, 908 

Pathology and Phenomena of Cretinism, 908 

Varieties of Cretinism, 908 

Cretins generally subjects of Goitre, ........ 908 

Geographical Districts where Cretinism Abounds, 908 

Stature of Cretins, 908 

Virchow's Dissections of Cretins' Heads, 908 

Eelation of Cretinism and Goitre to Soil, 909 

Symptoms of Cretinism, 910 

Hygienic Measures for the Prevention of Cretin-ism, 910 

Diabetes, ^ 911 

Definition of Diabetes 911 

Pathology of Diabetes, 911 

Diabetes Mellitus a Constitutional Affection, 911 



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Xlvi CONTENTS OF VOLUME I. 

PAGE 

Glycogenesis, 9ll 

Generation of Sugar by the Liver, 911 

Prevention of Sugar Formation, . . . 912 

Intermittent Diabetes, 913 

Influence of Diet on Formation of Sugar, 913 

Distinction of Sugar in the Blood in Health, 918 

Formation of Sugar in the Liver ; . . . . 913 

Keflex Excitement of Medulla Oblongata a Cause of Diabetes, . . . 914 

Bernard's Experimental Production of Diabetes, 914 

General Circumstances under which Melituria is Developed, . . . 914 

Relative Occurrence of Diabetes in Males and Females, . . . . 914 

Hereditary Origin and Transmission of Melituria, 914 

Morbid Anatomy in Diabetes, 914 

Secondary Lung Lesions, ...... .... 915 

Question as to their being Tubercular, 915 

Symptoms of Diabetes, 915 

Progressive Emaciation in Diabetes, . 915 

Condition of the Urine inDiabetes, 916 

Tests for Sugar in the Urine, '. 916 

Crystals of Diabetic Sugar from Diabetic Urine 916 

Trommer's Test for Sugar in the Urine, 910 

Fehling's Test for Sugar in the Urine, 916 

Sources of Sugar in the Urine in Diabetes, . . . . . . . 917 

Influence of Sugar, Starchy and Nitrogenous Food in producing Melituria, 917 

Relation between Food and Sugar in Diabetes, . . . . ■. . 917 

Sugar-formation at the Expense of the Muscles of the Body, . . . 918 

Inosite or Muscle-sugar Crystallized, , . . 918 

Relation of Urea and Sugar-formation in Diabetes, 918 

Chronic Nature of Diabetes, 919 

Duration of 100 Cases of Diabetes collected by Griesinger, .... 919 

Complication of Diabetes with Pulmonary Lesion and with Defective Vision, 919 

Cataract in Diabetes, 919 

Amblyopia in Diabetes, 920 

Prognosis in Diabetes, 920 

Treatment of Diabetes, . 920 

Management of Diabetes by Diet, 921 

Animal Diet in Diabetes, 921 

Mixed Diet in Diabetes, 921 

Abstinence from Sugar and Starch, . . . 922 

Milk Diet in Diabetes, 922 

Bran Cakes and Bread in Diabetes, 922 

Cod-liver Oil, . 923 

General Conclusions regarding Management of Diabetes, .... 923 

Purpura, 925 

Definition of Purpura, 925 

Pathology of Purpura, 925 

Varieties of Purpura, 925 

Simple Purpura, 925 

Hemorrhagic Purpura, 925 

Examination of Blood in Purpura, 925 

Symptoms and Causes of Purpura, 926 

Diagnosis between Purpura and Scurvy 926 

Treatment of Purpura, 927 

Scurvy, 928 

Definition of Scurvy, 928 

Pathology and Historical Notice of Scurvy, 928 

Circumstances under which Scurvy has Prevailed, 929 

Prevalence of Scurvy in the British and American Armies, . . . 929 

Morbid Anatomy of Scurvy, 929 

Chemical Pathology of Scurvy, 931 

Symptoms of Scurvy, 932 

Extravasations of Blood in Scurvy, 932 

Sites of Scorbutic Ulcers, 933 

Duration of Cases of Scurvy, 933 

Scorbutic Dysentery, 934 

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CONTENTS OF VOLUME I. xlvii 



PAGE 



- Night-blindness in Scurvy 03^ 

Tendency to Swoon in Scurvy, ■■....' 934 

Intercurrent Chest AflFections in Scurvy, . . . . ' 934 

Diagnosis of Scurvy, .' . ' ' 934 

Prognosis in Scurvy, .' . " 934 

Causes and Conditions under which Scurvy is Developed, '. ' ' .' 935 

Summary of Conditions producing Scurvy, . . ' ' ' 936 

Treatment of Scurvy, , _ ' ' " "937 

Prevalence of Scurvy in the Merchant Service, . . '. ' ' 938 

Prevention of Scurvy, '. . . 940' 

Anemia, .941 

Definition of Ansemia g^j 

Pathology of Ansemia, .'.'.'"' 941 

Eesults of Deficiency of Eed Corpuscles in the Bldod, . ". '. ' ' 941 

Symptoms of Anaemia, [ ' g^2 

Cardiac, Arterial, and Venous Murmurs in Ansemia, ...'.' 9i2 

Characters of Ansemic Murmurs, " ' 943 

Condition of the Urine in Anemia, ........ 944 

Causes of Anaemia, .' ." ' ' 944 

Treatment of Anaemia, .'.""" 945 

Tonic Treatment of Antemia, ' ' " .' ' 945 

Suggestions for the Use of Iron in Anasmia, ....... 945 

Formula, for the Preparation of Syrup of the Phosphates of Iron, Quinine! 

and Strychnia, , g^g 

Chlorosis, . . . _ _ g^y 

Definition of Chlorosis, 947 

Pathology and Symptoms of Chlorosis .'.'.' 947 

Implication of the Nervous System in Chlorosis, ....!." 947 

Disorder of Digestion in Chlorosis, . . 947 

Condition of Eespiratory, Generative, and Vascular System in Chlorosis, . 948 

Causes of Chlorosis, 943 

Diagnosis of Chlorosis, . . 948 

Treatment of Chlorosis by Pood and Medicine, .....'. 948 

General Deopst, gjO 

Definition of General Dropsy, 95O 

Pathology and Symptoms of General Dropsy, 950 

A Form of. Universal (Edema or Anasarca, 950 

Phenomena of " Pitting " under Pressure, 950 

Diagnosis of General Dropsy, ■ . _ 95O 

Treatment of General Dropsy, 9 50 

Beriberi, . ggo 

Definition of Beriberi, 950 

Pathology and Historical Notice of Beriberi, 95I 

Morbid Anatomy in Oases of Beriberi, 952 

Symptoms of Beriberi, 952 

Forms of Beriberi, . . . • 952 

Causes of Beriberi, 954 

Diagnosis of Beriberi, 955 

Prognosis in Cases of Beriberi; 955 

Sudden Death in Beriberi, 955 

Treatment of Beriberi, 956 

Composition of the Eastern Eemedy called " Treeak Farook," . . . 956 

CHAPTEE XII. 

Inpltjence of Food on some Constitutional Diseases described in the 

Previous Chapter, 957 

Principles of Construction of Dietaries for Large Bodies of Men, . . 958 

Amount of Food consumed by a Man, . . 959 



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xlviii CONTENTS OF VOLUME I. 

PAGE 

Kelatiou of Food to Body-weight 960 

Kelation of Pood and Disease, . 961 

Table of Nutritive Value of Foods (Parkes), in 100 parts, . . . .960 

Table of Dietaries and their Nutritive Values (Letheby) 961 

Table of. Nutritive Value of Foods (Letheby), 962 

Mean Amount of the Four Classes of Aliments (Playfair), .... 962 

Effects of Over-feeding ■ • 963 

Pathology of Corpulence, 963 

Dietary of Mr. Banting 964 

Effects of Deficient Food, • 964 

Death from Starvation, 965 

The " Truck-system " and its Evil Effects, . 966 

CHAPTER XIII. 

Genbkal Management oe the System Liable to Constittttional Dis- 
eases, 967 

Prevention/, Control, and Arrest of Farther Development the Basis of Man- 
agement, ............. 967 

General and Individual Hygienic Management, . . . . . . 967 

Three Periods in the Development of Constitutional . Diseases relative to 

their Management, 968 

Intervals of Abeyance of Disease or of Comparative Freedom from Disease 

to be taken advantage of in their Management, . . . " . . 968 

Management of Disease by Regulation of Diet, . , . . . . . . 968 

Management of Disease by the Use of Water, 970 

Management of Disease by the Aid of Wines and Alcoholic Beverages, . 970 

Properties of Wines and Alcoholic Beverages, . . . . . . 970 

Medicinal Substances contained in Wines, 970 

Rules for the Administration of Alcohol in Disease 970 

Determination of the Amount of Alcohol in Wine, ..... 971 

Determination of the Amount of Acidity in Wines, ..... 972 

Determination of the Amount of Sugar in Wines, 973 

Determination of the Amount of Solids in Wines, ..... 973 

Use of Wine and Alcoholic Beverages generally in Constitutional Diseases, 974 

CHAPTER XIV. 

General Nattteb of Local Diseases, 975 

Diseases comprehended under this head, 975 

Constitutional Symptoms of Local Affections, 975 

Secondary Symptoms of Lesions, . . 975 

Anatomical Forms' of the Local Lesions, ....... 975 

CHAPTER XV. 

Diseases op the Neuvous System, 976 

Section I. — Introduction to the Pathology of the Diseases of the 

Nervous System, 976 

How the Varied Phenomena of the Nervous System are to be viewed, . 976 

Constituents of Brain and Nerves, ......... 977 

Chemical Composition of the Brain and Nerve-tissue, 977 

Weight of the Brain and its Parts, 977 

Absolute Weight of the Brain, 977 

Table of Relative Averages of Body-weight, and the Weight of Cerebral 

Organs as to Age and Height, 978 

Bulk of the Encephalon, 978 

Specific Gravity of the Healthy Brain 978 

Specific Gravity of Central Ganglia, 979 

Pathological Relations of the Nervous Organs and Textures, . . . 980 

Cardinal Facts in the Physiology of the Nervous System illustrative of its • 

Pathology 980 



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CONTENTS OP VOLUME I. xUx 



PAGE 



Phenomena of Isolated Conduction, 980 

Phenomena of Sympathy or Irradiation, 981 

Phenomena of Intelligence, 981 

Nervous Force from Gray Matter 981 

Section II. — Guides to the Diagnosis ott Diseases of the Nervous 

System, 982 

I. As to Locality or Site of Lesion, 982 

Indications of the Cerebrum being Aflfeeted, 982 

Indications of the Meninges being Ail'ected, 982 

Indications of the Spinal Cord being AfTeoted 982 

General Grounds on which a Diagnosis may be made, . . 982 

Characters of Cerebral and Meningeal Diseases contrasted, . . 983 
Characters of Gastric or Hepatic Vomiting contrasted with Cerebral 

Vomiting, 984 

II. As to the Nature of the Affection, 984 

(a.) Acute but Non-febrile Symptoms of Diseases of the Nervous 

System 984 

(b.) Characters of Chronic Diseases of the Nervous System, . . 984 

Symptoms of Loss of Function, 984 

Symptoms of Irritation, 984 

III. As to the Anatomical Condition, 985 

IV. As to Urea in the Blood and Brain, 985 

Detection of Urea— (1.) In Serum; (2.) In Brain, . . . .986 

V. As to Morbid Textural Changes in the Brain, 986 

Principles on which Diseases of the Nervous System may be Arranged 

and Considered in Groups, 987 

Definition of Words in Common Use in Describing Diseases of the 

Nervous System, 987 

VI. As to Physical Conditions, 988 

(a.) Perversion of Sense of Touch and Power of Discrimination, . 988 

Dr. Sieveking's ^sthesiometer and its Use, 988 

Normal Distance Limits of Sensitiveness, ..... 988 

Eules for the Use of the JSsthesiometer, ...... 989 

(6.) Perversion of Muscular Power, ....... 990 

(c.) Perversion of Body-heat, . 991 

(d.) Perversion of the Power of Expressing Thought, . . . 991 

Theories of the Localization of Brain Lesion in Aphasia, . . 992 

Section III. — Diseases of the Brain and its Membranes, . . 993 

Encephalitis, 993 

Definition of Encephalitis, 993 

Pathology of Encephalitis, .......... 993 

Causes of Encephalitis 993 

Morbid Anatomy in Cases of Encephalitis, ....... 993 

Symptoms of Encephalitis, . . . . . . 994 

Cerebral as Distinct from Meningeal Symptoms, ...... 995 

Premonitory Symptoms of Cerebral Softening, ...... 995 

Diagnosis of Encephalitis, 995 

Treatment of Encephalitis, 995 

Meningitis, 995 

Definition of Meningitis, 995 

Pathology and Morbid ii-natomy of Meningitis, 996 

(1.) Inflammation of the Dura Mater, 996 

(2.) Inflammation of Pia Mater and Arachnoid, 996 

Phenomena of Arachnitis, 996 

Serum in Arachnoid Cavity, 996 

Suppurative Arachnitis, 996 

Characters of Chronic Arachnitis, 997 

(3.) Tubercular Meningitis (Acute Hydrocephalus), 997 

Causes of Meningitis, 998 

Symptoms and Diagnosis of Meningitis, 998 

(a.) Simple Meningitis, 998 

Mental, Sensorial, and Motorial Phenomena, 999 

VOL. I. ^^ ^ 

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CONTENTS OF VOLUME I. 



(J.) Tubercular Meningitis in the Child, . . ■ 
Mental, Sensorial, and Motorial Phenomena, 

(c.) Tubercular Meningitis in the Adult, 

Mental, Sensorial, and Motorial Phenomena, 
General Characteristics of Tubercular Meningitis 

(d.) Acute Meningitis in the Aged, 

Mental, Sensorial, and Motorial Phenomena, 

(e.) Chronic Meningitis of the Aged, . 

Mental, Sensorial, and Motorial Phenomena 
Diagnosis of Meningitis, . . . ^ 
Treatment of Meningitis, 

TUBKKOULAR MENINGITIS, .... 

Definition of Tubercular Meningitis, 

Pathology of Tubercular Meningitis, . 

Acute Hydrocephalus, .... 

Morbid Anatomy in Acute Hydrocephalus, 

Symptoms of Acute Hydrocephalus, 

Earliest Signs of Acute Hydrocephalus, 

Diagnosis of Acute Hydrocephalus, 

The Vomiting Characteristic of Acute Hydrocephak 

Spurious Hydrocephalus or Hydrocephaloid, 

Diagnosis of this Porm of Hydrocephalus, . 

Prognosis in Hydrocephalus, 

Treatment in Acute Hydrocephalus, 

Bloodletting in Tubercular Meningitis, 

Use of Medicines in Tubercular Meningitis, 

Management of Diet in Tubercular Meningitis, 

Inflammation of the Brain 

Definition of Inflammation of the Brain, 
Pathology of Inflammation of the Brain, 
Morbid Anatomy in Inflammation of the Brain, 
Results of Inflammation of the Brain, . 
Symptoms of Inflammation of the Brain, 
Mental, Motorial, and Sensorial Phenomena, 
Treatment (see Encephalitis and Meningitis), 

Bbd Softening of the Brain, . . ' . 

Deflnition of Bed Softening of the Brain, . 

Pathology of Bed Softening of the Brain, . 

Several Morbid Conditions to he Distinguished within the 

Symptoms of lied Softening of the Brain, 

Mental, Sensorial, and Motorial Symptorns of Softening of- 

Combination of Symptoms indicative of Softening, 

Duration of Life in EamoUissement of the Brain, 

Diagnosis of Bed Softening of the Brain, . 

Prognosis in Cases of Bed Softening of the Brain, 

Treatment of Inflammatory Softening, 

Yellow Softening or the Brain, 

Definition of Yellow Softening of the Brain, 
Pathology of Yellow Softening of the Brain, 
Symptoms of Yellow Softening of the Brain, 
Conditions under which Softening (post-mortem) is seen, 
Conditions producing Softening, . 
Diagnosis of Softening, 
Treatment of Softening, 

Abscess of the Brain, .... 

Definition of Abscess of the Brain, 

Pathology of Abscess of the Brain, 

Morbid Anatomy in Cases of Abscess of the Brain, 

Locality" of Abscesses in the Brain, 

Causes of Cerebral Abscess, . 



the 



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CONTENTS OF VOLUME I. 11 

PAGE 

Symptoms of Cerebral Abscess, . 1020 

Diagnosis of Cerebral Abscess . 1020 

Apoplexy, 1021 

Definition of Apoplexy, . 1021 

Pathology of Apoplexy, 1021 

Group of Symptoms Characterizing Apoplexy, 1021 

Local Lesions Inducing Apoplexy, . ." 1021 

Theories to Explain the Apoplectic State, 1022 

Morbid Anatomy in Cases of Apoplexy, 1022 

Changes in the Blood Effused, 1023 

Position of Blood Effused in Apoplexy, . . . . . . . 1024 

(a.) Superficial or Ventricular Extravasation, 1024 

(6.) Extravasation in the Substance of the Hemispheres, .... 1025 

(c.) Extravasation in the Pons Varolii and other Parts, .... 1026 

Comparative Liability of Parts of the Brain to Extravasation, . . 1027 

Circumstances under which Extravasation Occurs, .... 1028 

Symptoms of Apoplexy, 1028 

I. Symptoms of Apoplexy from Congestion, 1028 

Mental, Sensorial, and Motorial Phenomena, 1029 

Precursory Symptoms or " "Warnings " of Apoplexy, . . . . 1029 

Special Nervous Symptoms Characteristic of Congestive Apoplexy, . 1029 

Diagnostic Value of Symptoms Combined in Groups, .... 1030 

II. Symptoms of Apoplexy from Hemorrhage, 1030 

A. Into the Cerebral Substance of the Hemispheres, .... 1030 

The "Stroke of Apoplexy," 1030 

Mental, Sensorial, and Motorial Phenomena, 1030 

Combination of Symptoms Characteristic of Hemorrhage in the 

Hemispheres, 1031 

B. Symptoms of Hemorrhage into the Ventricles, .... 1032 
Mental and Motorial Symptoms, 1032 

c. Symptoms of Arachnoid Hemorrhage, 1032 

Combination of Symptoms Characteristic of Subarachnoid Hemor- 
rhage, . 1032 

Causes of Apoplexy, 1033 

Anatomical Lesions, 1033 

Connection of Apoplexy with Heart and Kidney Disease, .... 1033 

Influence of Temperature in causing Apoplexy, 1034 

Influence of Moral Causes in producing Apoplexy, 1034 

Influence of Mechanical Obstruction and Violence, . • . . . . 1034 

Occurrence of Apoplexy in Childhood, ....... 1034 

Influence of Sex, Progress of Digestion, and Conditions of the Body Pre- 
disposing to Apoplexy, . - 1034 

Prognosis in Cases of Apoplexy, 1034 

Treatment of Apoplexy, 1036 

Question of Bloodletting in Apoplexy, 1037 

Purgation in Apoplexy, . . . . . . . . . . 1038 

Turpentine, Castor Oil, and Croton Oil Enemata, 1038 

Dietetic Treatment of Apoplexy, 1038 

Hjematoma of the Duba Matek, 1039 

Definition of Hfematoma of the Dura Mater, 1039 

Pathology of Hsematoma of the Dura Mater, 1039 

Morbid Anatomy of the Blood Extravasation, 1039 

Symptoms of Hsematoma, . . . . 1040 

Treatment of Hsematoma, 1040 

Sunstroke, 1040 

Definition of Sunstroke 1040 

Pathology and Symptoms of Sunstroke, 1040 

Circumstances under which Sunstroke has Occurred, 1041 

Sunstroke occurring on the March or in the Eield, 1041 

Influence of Vitiated Air in producing Sunstroke, 1043 

Condition of the Atmosphere and as to Heat, 1043 

Sunstroke occurring " in Quarters " or in Tents, 1043 

Premonitory Phenomena of Sunstroke, 1044 



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lii CONTENTS OP VOLUME I. 

PAGE 

The Urine in Sunstroke, . . . 1044 

Periods of Attack in Sunstroke, ... . . . . . . . 1045 

Constant Symptoms of Sunstroke, . . . . .. ' . . . 1046 

Body-temperature in Sunstroke, 1046 

Heart's Action in Sunstroke, 1046 

Symptoms of a Fatal End, . . - 1047 

Mortality from Sunstroke, . 1047 

Symptoms of a Favorable End, . . 1047 

Morbid Anatomy in Cases of Sunstroke, 1048 

Condition of the Blood in Sunstroke, 1048 

Theories regarding Mode of Action of Heat in producing Sunstroke, . 1048 

Modes of Death in Sunstroke, 1049 

Causes of Sunstroke, . . ... . 1050 

Treatment of Sunstroke, 1050 

Measures for the Prevention of Sunstroke, . . . . . . . 1052 



APPENDIX TO VOL. I. 

Circumstances connected with the Origin of Specific Yellow Fever, . . . 1054 



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LIST OF ILLUSTEATIONS IN VOL. I. 



riG. PAGE 

1. Dilated Bloodvessels in Inflammation (after Paget), 72 

2. Pareucliymatous Inflammation, or Cloudy Swelling, as seen in a Convoluted 

Urinary Tubule taken from the Cortex of a Kidney in Bright's Disease 

(after Virchow), 79 

3. Diagram showing Records of Temperature in a Case of Hectic Pever (Croft), 100 

4. Lymph Cells from Inflamed Pleura (Paget and Turner), .... 101 

5. Nuclei in Fibrinous Product of Inflammation De'veloping into Pibres (Ben- 

nett), 102 

6. Eibro-plastic Cells of Lymph developing into Pibres (Bennett), . . . 102 

7. Perfect "White Fibrous Tissue from Lymph (Bennett) 102 

8. Pigment from an Apoplectic Cicatrix in the Brain (Virchow), . . .113 

9. Crystals of Hjematoidin in different forms (Virchow), .... 113 

10. Hepatic Cells— (1.) Normal; (2.) Affected with Hypertrophy ; (3.) Affected 

with Hyperplasy — Numerical Increase or Adjunctive Hypertrophy (Vir- 
chow), 121 

11, 12. Kokitansky's Representations of the Minute Structure of Cysts, . 138, 139 

13. Slightly Magnified Cyst of Trichina Spiralis (Virchow), .... 154 

14. Trichina Spiralis removed from the Cyst (Virchow), 154 

15. Diagram of the Head or Anterior end of the Guinea-worm (Bastian), . . 166 

16. Various Forms of the Caudal End of the Guinea-worm (Busk, Carter, and 

Greenhow), 166 

17. Dissection of a Guinea-worm (Bastian), . 167 

18. Dissection of Anterior Extremity of Guinea-worm (Greenhow), . . . 167 

19. A. Transverse Section of Adult Guinea-worm (Bastian), .... 168 
B. Toung of the Guinea-worm more or less Spirally Curved (Bastian), . 168 

20. Head of the Bothriocephalus Latus 178 

21. Operculated Ova of Bothriocephalus, 179 

22. Bothriocephalus Cordatus, Natural Size and Magnified, ' . . . . 179 

23. Head and Neck of Taenia Solium, showing Circle of Hooks, . . . 180 

24. Circle of Hooks in Head of Tajnia Solium, highly Magnified (Leuckart), . 181 

25. Proglottis of Ttenia Solium, Magnified (Rokitansky), 182 

26. Proglottides of Taenia in Various Stages of Contraction (Leuckart), . . 182 

27. Development of the Ovum of Taenia Solium, 183 

28. Head of the Tasnia Mediocanellata, 186 

29. Groups of Echinococci (Erasmus Wilson), 189 

(1.) and (2.) Singly Pediculated in Groups, 189 

30. Echinococci from a "Hydatid Tumor," 189 

31 . A. Transverse View of the Head of an Echinococcus, showing Suctorial Disks 

and Hooklets, 190' 

32. B. Circle of (34) Hooklets seen on its Under Surface, 190 

0. Lateral Views of Separate Hooklets, 190 

33. Two Specimens of Cysticercus Mediocanellata, Natural Size, taken from a 

■ Specimen of Ration-beef sent from the Punjaub, 194 

34. Head of one of these Specimens Magnified 65 Diameters, .... 195 

35. Head of Cysticercus Cellulose, to contrast with the Taenia Mediocanellata, . 195 

36. (a.) Operculated Ovum of Distoma; (6.) Opalina, 203 

37. (1.) Ovum of Distoma Haematobium ; (2.) Embryo (Ciliated) from Ovum 

Capsule; (3.) Embryo attached to the Ovum Capsule from HsBmatobia, at 

the Cape of Good Hope (Dr. John Harley) 206 

38 Small portion of the Lung of an African Soldier with a Pentastoma Constric- 

tum curled up in its Cyst (Dr. Humphry C. Gillespie), . . . .208 

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liv LIST OF ILLUSTRATIONS IN VOL. I. 

FIG. ' PA&E 

39. Two Specimens of Pentastoma Constrictuni removed from their Cysts, and 

of the Natural Size (Dr. Humphry C. Gillespie), . . . . .208 

40. Two Specimens of Pentastoma Constrictum, Magnified from 3 to 5 Diameters 

— (a.) the Shorter ; (5.) and (a.) Posterior and Anterior Aspects of the 
Longer Parasite (Dr. Humphry C. Gillespie), 209 

41. Anterior Aspect of the Flattened Head of the Parasite, to show its five spots 

or marks (Dr. Humphry C. Gillespie), 209 

42. Portion of Liver containing Encysted Specimens of Pentastoma Constrictum, 

from a Private in a West India Regiment, in the Museum of the Army 
Medical Department since 1854, Drawn by Dr. H. C. Gillespie, . . 211 
48. Larva or Grub from Bulama Boil (Dr. Albert Gore), 212 

44. Larva or Grub from Boil, Magnified, showing — n, a, Hollow Suction Tubes; 

(b.) Fine Red Spots and Hooklets over Body (Dr. A. Gore), . . .212 

45. Hooklets, highly Magnified (Dr. A. Gore), 212 

46. The Crab-louse, X 10 Diameters (Dr.. T. Anderson), 213 

47. (a), Pedieulus Capitis (male) ; (6), Trachea and Stigmata; (c), Antennse (Dr. 

T. Anderson), 214 

48. Nit, or Egg Capsule of the Louse, fixed to (6) a hair by a Glutinous Secre- 

tion (c, c, a), 214 

49. Pedieulus Corporis — Female (Dr. T. Anderson), 215 

50. Acarus Scabiei — Female (Dr. T. Anderson), 216 

51. Acarus Scabiei— Male (Dr. T. Anderson), 217 

52. Development of the Acarns Scabiei — a, b, c, d, e, Egg in Different Stages of 

advancement (Dr. T. Anderson), . 218 

53. Larva or Young of Acarus Scabiei (Dr. T. Anderson), 219 

54. Demodex Folliculorum (Dr. T. Anderson) 219 

55. Crystals of Margarine (Robin and Verdeil), 229 

56. Fat Cells, inclosing Crystals of Margarine (Wedl), . . . . . 229 

57. Margario Acid (Beale), 230 

58. Cholesterin Plates — (a.) Regularly Laminated ; (b.) Irregularly Laminated 

and Injured Forms, X 300 Diameters (Wedl), 230 

59. Crystals of Uric Acid — [a.) Rhomboidal, Truncated, Hexahedral, and Lami- 

nated; (6.) Rhombic Prisms; (c.) Barrel-shaped Prisms; (rf.) Cvlindrical 
Forms, X 300 Diameters (Wedl),. " . . 231 

60. [a.) Urate of Ammonia in Globules; (6.) As a Fine Sandy Concretion in 

Kidney Tubes of a Child; (c.) Angular Molecules, , 231 

61. Crystals of Oxalate of Lime (Wedl), 232 

62. Usual Forms of Triple Phosphate of Magnesia and Ammonia (Wedl), . 232 

63. Double Embryo from a Fowl's Egg after sixteen to eighteen hours' Incu- 

bation, Magnified four times— (fi.) Germinal Area of Oicatrlcula; [b.) 
Transparent Area, containing two Primitive Traces of Embryos; (c, c.) 
Primitive Grooves of the Double Embryonic Trace, on each side of which 
are seen the Laminae Dorsalis (after Dr. Allen Thomson), . . . 238 

64. Double Embryo from a Goose's Egg after five days' Incubation, Magnified 

four times; [g.) The Common Heart; (A.) Rudiments of the Superior; (i.) 
Of the Inferior Extremities ; (k.) The Common Cephalic Fold of the Am- 
nios; (i ) The Caudal Folds (after Dr. Allen Thomson), . . . .288 

65. Curved Clinical Thermometer for Reading in situ the Bodily Temperature in 

the Axilla, 244 

66. Phillips's Registering Maximum Thermometer for Clinical Investigation, . 244 

67. Changes said by Dr. Halford to occur in the Blood-corpuscles subsequent to 

the Bite of the Cobra di Capello, x 1050, 365 

68. Similar appearance x 400, \ 365 

69. Diagram of the Typical Range of Body-temperature in a Case of Natural 

Small-pox (Wunderlich), 381 

70. Diagram of Typical Range of Body-temperature in a Case of Smail-pox 

Modified by Vaccination (Wunderlich), 389 

71. Diagram Representing the Range of Body-temperature in a Severe Case of 

Measles (Wunderlich), 426 

72. Diagram Typical of Body-temperature in a Case of Scarlet Fever (Wunder- 

lich), 439 

73. Diagram Typical of Body-temperature in Typhus (Wunderlich and Mao- 

lagan), 467 

74. Range of Body-temperature in a Severe and Prolonged Case of Enteric Fever 

,, (Wunderlich), 530 

75. Diagram of Range of Body-temperature in a Case of Relapsing Fever (Her- 

^i"). 556 



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LIST OP ILLUSTRATIONS IN VOL. I. Iv 

MG. PAGl! 

76. Diagram of Typical Eange of Body-temperature in a Case of Pebricula 

(Wunderlich), . ' 563 

77. Diagram of Typical Eange of Body-temperature in a Case of Protracted Peb- 

ricula (Wunderlich), 563 

78. Diagram of Typical JRange of Body-temperature in a Case of Intermittent 

Pever or Quotidian Ague (Wunderlich), 588 

79. Diagram of Typical Eange of Body-temperature in a Case of Intermittent 

Pever of Tertian Type (Wunderlich), 5S9 

80. Diagranmtic Eepresentation of the State of the Heart, Lungs, and Great 

Vessels, after Death, in Collapse of Cholera (after Dr. George Johnson), . 642 

81. Diagram of Typical 'Eange of Body-temperature in a Case of Erysipelas 

affecting the Pace (C. L. Pox), 727 

82. Diagram of Body-temperature in a Case of PyEeniia (Einger), . . . 743 

83. Diagram Typical of Body-temperatureina Case of Acute Eheumatism affect- 

ing many Joints (Wunderlich), 762 

84. Urate of Soda in Stellai-form Crystals (Wedl), 784 

85. Appearance of the Teeth in Hereditary Syphilis 839 

86. Cancer-cells of Scirrhus filling the Interstices among Bundles of Connective 

Tissue in the Skin of the Breast (Paget), 851 

87. Varied Porms of the Elementary Cells of Scirrhus Cancer (after Wedl and 

Paget), 852 

88. Varied Porms of the Elements of Soft or Medullary Cancer (after Paget and 

Wedl), 853 

89. Various Typical Epithelial Cancer-cells and their Arrangement (after Paget 

and Eokitansky), 857 

90. Various cells of Melanotic Cancer from the Orbit (after Wedl), . . . 858 

91. Development of Tubercle from Connective Tissue in the Pleura — 300 Diame- 

ters (after Virchow), , . . 882 

92. Crystals of Diabetic Sugar from Diabetic Urine (after Beale), . . . 916 

93. Inosite, or Muscle-sugar, Crystallized partly from Alcohol and partly from 

Water (after Punke), 918 

94. Nitrate of [Jrea (after Beale), 986 

95. jEsthesiometer of Dr. Sieveking, 988 

96. Dynamometer of Mathieu for measuring the Strength of Paralyzed Muscles, 991 



Engraved Plate, showing Porms of Pungi as described by Hallier and others in 

Eice-water Stools of Cholera, to face jiage 649 



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THE 



SCIENCE Al^D PRACTICE OF MEDICINE. 



PAET I. 

TOPICS RELATIVE TO PATHOLOGY. 



CHAPTER I. 



OF MEDICINE AS A SCIENCE AND AS AN ART; ITS OBJECTS AND ITS 

EXTENT. 

The study of Medicine is prosecuted under two relations, namely, as a 
Science and as an Art. 

Considered as a Science, Medicine takes cognizance of all that relates to 
our knowledge of diseases ; and, especially, of the circumstances under which 
they become developed, of the conditions of their existence, of their nature 
and of their causes, in the widest sense of these terms. 

Considered as an Art (in so far as Medicine has that practical value), its 
object and aim is to distinguish, to prevent, and to cure diseases ; to alleviate 
human suffering, and to lengthen out human existence, by warding off or by 
modifying disease " as the greatest of mortal evils," and by restoring health, 
and even at times reason itself, " as the greatest of mortal blessings." 

In general terms, the practical view required to be taken of Medicine is, 
that " it is the art of understanding the nature of diseases, in order to appre- 
ciate their causes, and to prevent their occurrence when possible ; to promote 
their cure, or to relieve those who suffer from them." 

Many branches of human knowledge are combined in the constitution and 
elucidation of the Science of Medicine. The practice of the Art ought to be 
founded on principles and facts of universal applicability. 

A consideration of the different topics of human knowledge which together 
make up the Science of Medicine suggests its division into the following 
departments, namely : 

(1.) Physiology, which embraces the study of the healthy functions of 
which the human body is the seat or instrument ; 

(2.) Pathology, subdivided into Special Pathology and General Pathology, 
which together embrace a consideration of everything relative to the existence 
and nature of diseases ; 

VOL. I. 4 

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50 TOPICS EBLATIVE TO PATHOLOGY. 

(3.) Therapeutics, whicli expounds the various actions of remedies upon 
the diseased economy, or the means by which Nature may be aided in her 
return to health ; -, f- ■ 

(4.) Hygiene, which embraces a consideration of the means ot preventmg 
disease, or, in other words, of preserving health. 

Physiology, General Pathology, Therapeutics, and Hygiene are sometimes 
designated indifferently by the titles of the "Institutes," the " Institutwm, or 
the " Theory of Medicine." 

These departments of science are all preliminary subjects of study, and 
constitute a necessary and appropriate introduction to the Practice of Physic, 
in which Special Pathology and the treatment of special diseases are the 
leading topics of consideration. 

Each of these departments has grown or expanded itself into a great branch 
of science; and any single section is suf&cient of itself to occupy the lifetime 
of an individual in working out and studying it in detail. It is, therefore, 
not possible for the human mind to embrace all of these departments in their 
whole extent or relations to each other ; and, setting aside the consideration 
of theories and systems, it has been truly observed, " that no man possesses 
all the pathological knowledge contained in the records of his art" (Chomel). 
Still less possible is it to embrace in any single treatise a complete and con- 
nected view of the Science of Medicine in all of these departments. 

For the purpose of teaching the Science of Medicine in its application to 
practice, its elementary principles, as developed in the departments of Pa- 
thology, are the most useful guides to the student ; and the aim of the follow- 
ing chapters, relative to Pathology, is to elucidate these principles. 



CHAPTER II. 

HOW THE PEOVINCE OF PATHOLOGY IS MAPPED OUT. 

An inquiry into the nature of diseases embraces a consideration of the fol- 
lowing topics : 

(1.) The accurate observation and correct registration of Facts in Pathology. 

On the efficiency of the machinery devised for these important ends will 
rest our . power to curb the invasion of our science by the guesswork of 
theory ; and eventually to root out the traditional errors which so largely 
pervade medical literature. 

(2.) Descriptive Pathology, emhraeing General and Special Pathology. 

Special Pathology is intended to comprehend a consideration of the essential 
nature and origin of particular diseases as they occur in man and animals, 
and General Pathology to include those more general facts or principles which 
result from a comparison of particular diseases with each other. Althotigh . 
Special Pathology comes first in the order of Nature, yet, wherever the ar- 
rangements for medical education are complete. General Pathology is taught 
as an introduction to, or conjointly with, the special study of diseases, just as 
in other sciences ; for example, in chemistry it is found convenient to give a 
general view of the principles which have been established by experiment and 
observation, before entering upon the particular details of the science. All 
theory in Medicine, all Descriptive Pathology, all grounds for rational specu- 
lation regarding the nature of diseases, and for the framing of experiments, as 
well as all maxims of practice which aim at the prevention or cure of diseases, 
must rest ultimately on observed and recorded facts. Accuracy of observation 
is therefore the first lesson the student has to learn in all methods of investi- 



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THE PROVINCE OF PATHOLOGY. 51 

gation, and the lesson is one of paramount importance. The best observa- 
tions, however, will avail but little unless the observed facts are recorded in 
such a way as to secure, their preservation ; and Descriptive Pathology mainly 
concerns itself, in the first instance, with the Registration of Facts, as em- 
braced, — 

(a.) In the Histm'y of cases of disease from their origin to their end. 

(6.) In the Statistics of disease. 

Such registration includes methods for preserving, in an authentic and per- 
manent form, the memory of Facts in Pathology as they occur. It thus 
eventually furnishes materials upon which future pathologists and statists will 
build a comprehensive and definite system of scientific Medicine. It will 
furnish the means of teaching all that is necessarily involved in our notions 
regarding the nature of diseases. The Descriptive Pathology, so arrived at, 
considers diseases as they exist, or have existed in man, in the lower animals, 
or in plants. It considers the conditions under which diseases originate ; it 
considers how far certain conditions are fulfilled before disease establishes 
itself; and it aims at demonstrating how far such conditions are inconsistent 
or incompatible with the maintenance of health. Subsequently, with ex- 
tended information. Descriptive Pathology may undertake to assign the con- 
ditions which give rise to certain diseases rather than to others. It will 
eventually define the elements necessary to establish, to originate, or to con- 
stitute particular diseases; and will show how the same disease, or class of 
diseases, may assume various forms, but in all of which definite elements are 
recognizable. Descriptive Pathology thus aims at determining and describ- 
ing the essential elements of a disease. 

(3.) Speculative Pathology assumes that we know what a disease is — that we 
know the eifects it produces — that we know the conditions necessary for its 
existence — that we know its relations to other diseases. It seeks to inquire 
how certain conditions or circumstances will operate in bringing about dis- 
ease. It seeks to determine the tendency in the future of a diseased state 
from certain observed facts in its course, or in the course of similar diseases. 
Statistical data are thus the main basis of its operations. 

(4.) Pathology dictates the maxims of rational practice. It is in the nature 
of the science of Pathology that it always ought to be in advance of our certain 
knowledge regarding the treatment of diseases. It is the basis of rational 
medicine; for it is rational to know the nature of a disease, in order (1.) To 
enable us to prevent it; (2.) To understand the principles which ought to 
guide us in the management of it. Such are the main divisions which the 
province of Pathology embraces. 

It is intended, however, in the first part of this handbook merely to guide 
the student to appreciate, — 

(1.) The relative nature of the tei-ms "Life," "Health," "Disease." 

(2.) How the nature and causes of diseases may be elucidated. 

(3.) The nature of morbid phenomena, symptoms, and signs of disease. 

(4.) The means ai;d instruments of investigation into the nature and causes 
-of disease. 

(5.) Some of the more elementary constituents of disease. 

(6.) Some complex morbid states associated with individual diseases, or 
with conditions of ill-health (cachexia). 

(7.) The modes by which diseases terminate fatally ; the types of disease,. 
and their tendency to change. 

(8.) The general treatment of the more complicated morbid states of the 
system comprehended under the name of General Diseases. 

In the subsequent parts of this work it is intended to consider some of the 
•details of the Science and Practice of Medicine : to furnish the student with, — 

(1.) A nosological system by which to classify and name diseases. 

,(.2.) A detailed description of characteristic diseases in the respective classes- 

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52 TOPICS RELATIVE TO PATHOLOGY. 

of that nosological arrangement. In this part a definition (provisional) and 
a history of the nature of each disease will be given ; the probable course and 
succession of events in the progress of each disease will be described, and 
the grounds on which an accurate diagnosis may be made, or a prognosis 
expected ; and, lastly, a detailed account of those rational modes of treat- 
ment which are consistent with the established principles of the Institutes of 
Medicine. 

(3.) An account of what is known relative to the geographical distribution 
of diseases. 



CHAPTER III. 

RELATIVE NATURE OP THE TERMS LIFJE, HEALTH, DISEASE. 

The word Disease is used in a general and also in a specific sense ; as when 
it is said that a person is diseased, without the nature of the afiTection being 
stated; or, that he suffers from a particular disease, such as small-pox. 
Attempts to give a precise definition of the term Disease have all been unsuc- 
cessful. The relations of the morbid state to the condition of health, and of 
health to the performance of the vital functions, are of such a kind that they 
can merely be described in connection, comparison, or contrast with each 
other, but not defined. 

If Life is understood to imply an active state, resulting from the concur- 
rent exercise of the functions of the body, then there are conditions of activity 
and of mutual adaptability of functions and of parts, both as regards body 
and mind, which are necessary to healthy existence. Our notions of the con- 
ditions of health have thus considerable latitude ; and Health is merely a name 
we give to that state or condition in which a person exists fully able, without 
sufiering, to perform all the functions and duties of life. Many degrees of 
Health are therefore at first sight obvious, from the possession of a feeble 
existence to the most robust condition of the body ; and there are even many 
degrees of feebleness and delicacy of Health without any disorder of the 
system. Our notions of normal life are thus so extremely indefinite that it is 
only by a forced abstraction the normal can be separated from the abnormal. 
Hence also our idea of Disease is very indefinite ; it cannot be separated by 
any well-defined boundary from our idea of normal life, and the two condi- 
tions are connected by a kind of debatable border land. 

When we regard, therefore, the phenomena of the living state and the con- 
ditions of health, we can readily observe when and how Disease is but A de- 
viation prom THE STATE OF HEALTH, CONSISTING POR THE MOST PART IN A 
CHANGE IN THE PROPERTIES OR STRUCTURE OF ANY TISSUE OR ORGAN, WHICH 
RENDERS SUCH TISSUE OR ORGAN UNFIT POR THE PERFORMANCE OP ITS 
ACTIONS OR FUNCTIONS ACCORDING TO THE LAWS OF THE HEALTHY FRAME. . 

It is now a received pathological doctrine that Disease does not consist in 
any single state or special existence, but is the natural expression of a combi- 
nation of phenomena, arising out of impaired function or altered structure. 
All attempts, therefore, to define disease by the use of such terms as " derange- 
ment," " modijieation," " alteration," " change," from the pre-existent state of 
health, show, in the first instance, that, in use, various ideas are attachable to 
the terms or to the state to which they are meant to ap^ply, and, secondly, that 
these terms point to a nosological division into structural and functional 
diseases, rather than to a state common to all forms of disease. 

A definition of any state of disease ought, therefore, to include all the cir- 
cumstances, whether functional or organic, which constitute the deviation 

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MORBID PHENOMENA, SYMPTOMS AND SIGNS OE DISEASE. 53 

from health ; and for obvious reasons such a definition can only be approxi- 
mately expressed, very incompletely circumscribing the subject by shadowy 
outlines. 



CHAPTER IV. 

HOW THE -NATURE AND CAUSES OP DISEASES MAY BE ELUCIDATED. 

The nature of the derangements to which the human body is liable may be 
studied under the three following aspects : 

(1.) As diseases present themselves in individual cases, becoming thereby 
the subjects of Clinical Investigation and Instruction — a method of 
teaching in which the Natural History of the disease ought to be a special 
subject of study. 

(2.) As they constitute particular genera or species of disease, forming the 
topics of Special Pathology. 

(3.) As they may be reduced to and studied in their primary elements, 
forming thereby the science of General Pathology. 

But, in whatever aspect we may view disease, there is invariably presented 
to the student the same subjects for investigation, namely, — First, The morbid 
phenomena or symptoms by which we become aware that derangements have 
taken place in the economy. It is by a mental eifort that either the student 
or the physician converts these symptoms into signs of disease ; and hence 
arises the necessity of studying Symptomatology or Semeiology. Second, The 
agents by which derangements and diseases are produced, generated, or brought 
about, constituting the department of Etiology. Third, The seats or localities 
of disease, or of derangements, constituting Pathogeny. Here the peculiar 
nature, general forms, and types of disease must be studied, together with va- 
rieties in their course, duration, and termination. Fourth, The morbid altera- 
tions discoverable in the structure of the body before, l3ut more especially 
after death, constituting Morbid Anatomy. These alterations must be studied 
in connection with the symptoms, the causes, and the course of the disease. 
Lastly, The elementary constituents of disease-products, constituting Morbid 
Histology, must be recognized in the first instance, and contrasted with analo- 
gous constituents of the body in the healthy state. 



CHAPTER V. 

of morbid PHENOMENA, SYMPTOMS, AND SIGNS OF DISEASE. 

It has been stated that only by a mental effort is the student or physician 
able to convert symptoms into signs of disease. Therefore the idea associated 
with "sign" is of a much more comprehensive kind than that which is con- 
nected with the word " symptom : " the former implies the possession of more 
extensive knowledge — a knowledge such that comparisons may be instituted 
amongst the symptoms which present themselves. Certain symptoms of 
disease, or of disordered function, are thus recognized to be peculiar, charac- 
teristic, or significant of a particular morbid state. A symptom, is thus con- 
verted into a sign, and what is called a diagnosis of the disease is made. 

Symptoms and signs of disease derive their importance from the fact that 
they are capable of being connected with lesions of structure or disorders of 

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54 TOPICS RELATIVE TO PATHOLO&Y. 

function ; and both of these conditions mutually act and react upon each 
other. Thus it is that such mutual reaction greatly aggravates any general 
disease. In place of the concurrent exercise of function, and the mutual co- 
operation of parts in a state of health, both as regards mind and body, we 
have symptoms of disease expressed in various ways, characteristic of the func- 
tion at fault, and incompatible with the normal existence of the part or organ 
affected, or of the body generally. From such phenomena the physician 
makes up his mind, — (1.) As to whether or not disease exists (2.) How far 
the condition of the patient is remoyed from the state of health usual to him. 
(3.) As to the nature of the disease, and how it is distinguished from other 
ailments, or in what respects it may differ from the same ailment in other 
people in similar circumstances. Thus a diagnosis is made by the art of con- 
verting symptoms into signs of disease. 

But the physician at the same time generally carries his misntal exertion a 
little further. He tries to arrive at a just estimate of the probable result or 
event of the malady, and so makes up his mind, — (4.) As to whether the ill- 
ness will terminate in the death of the patient, in permanent organic mischief 
of greater or less extent, in persistent impairment of the general health 
(cachexise), or in complete recovery. As in Politics, so in the Science of 
Medicine : the Politician and the Physician have each to deal with the future, 
as well as with the present. Both endeavor to forecast events ; and thus, in 
the Practice of Medicine, we are said to make or give a prognosis. (5.) The 
Physician must be able also to appreciate with reasonable rapidity those 
symptoms which are peculiar, and to recognize them when associated together 
as the signs of particular or definite morbid states. Such symptoms are then 
said to furnish pathognomonic signs of disease. (6.) The Physician must further 
discriminate, and try to put a fair and just value or interpretation upon, those 
symptoms which are only experienced by the sensations (subjective) of the 
patient himself, as contrasted with those which may be seen or appreciated by 
others — such as objective phenomena or physical signs. 

The interpretation of symptoms can only be successful after a close observa- 
tion of- the patient — often prolonged, and repeated for more complete investi- 
gation — so as to connect the results arrived at with his previous history. The 
utmost logical acumen is required for the due interpretation of symptoms. 
The individual value of each ought to be duly weighed ; one symptom must 
be compared with another, and each with all ; while the liability to variation 
of a similar symptom in different cases of a like kind must not be forgotten ; 
and the occasional absence of the usual pathognomonic signs may be some- 
times calculated upon. Thus only can the nature of a disease be clearly deter- 
mined — its severity and dangers fully appreciated — its treatment indicated, 
and the probability of recovery foretold. 

A close observation of the general symptoms of diseases, in all their details, 
is absolutely necessary ; and the investigation is aided practically by the 
improved instruments of the present day, and the better methods of examina- 
tion of patients. Above all things, methodical examination is essential for the 
student, if he would acquire the habit of carefully and accurately learning the 
nature of the cases of disease with which he will have to deal. Patients must be 
examined methodically, in order that the symptoms of disease may be correctly 
interpreted, and that nothing be overlooked or neglected. Directions have 
been given by many authorities for acquiring and habitually following a defi- 
nite system of examining patients, as to what are the essential data to be 
■obtained and recorded in case-taking ; and although, as Dr. Acland justly 
remarks, a skilful practitioner can learn the truth of most cases in any order, 
or in no order, yet it is highly desirable that a regular order should be fol- 
lowed by learners ; and all cases observed by the student should be methodi- 
cally entered in a note-book for the purpose. This habit will thus eventually 



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MORBID ANATOMY AND PATHOLOGICAL HISTOLOGY. 55 

become a necessity, and will be found most useful in after-life, and especially 
in consulting practice. 

The following works are recommended for study, and as guides for acquir- 
ing the best methods of observing and recording cases : (1.) A Manual of 
Medical Diagnosis, third edition, by A. W. Barclay, M.D. ; (2.) A Handbook of 
Hospital Practice ; or, an Introduction to the Practical Study of Medicine at the 
Bedside, by Robert D. Lyons, M.B., Professor of Medicine in the Catholic 
University of Ireland ; (3.) An Introduction to Clinical Medicine, by John 
Hughes Bennett, M.D., Senior Professor of Clinical Medicine in the Univer- 
sity of Edinburgh ; (4.) " Suggestions for taking Cases," by Dr. Beale, Archives 
of Medicine, vol. iii, p. 47. 



CHAPTER VI. 



MORBID ANATOMY AND PATHOLOGICAL HISTOLOGY: THE SPECIAL MEANS 
AND INSTRUMENTS BY WHICH THE NATURE OF DISEASES MAY BE INVES- 
TIGATED. 

Morbid, or, as it is also sometimes called. Pathological Anatomy, is 
that department of medical science which treats of the changes produced by 
disease in the solids and fluids of the body ; while Morbid or Pathological 
Histology treats of the origin, development, growth, and decay of the new 
products or new formations which are the elementary constituents of structu- 
ral or organic lesions. The anatomy of diseased parts stands in the same rela- 
tion to the development of morbid phenomena and conditions of disease that 
the anatomy of healthy structures and the histology of the textures do to the 
natural functions and processes of development, growth, and nutrition in the 
healthy body. 

The vestiges left by the prolonged existence of a morbid state, whether in 
the body of man or of the lower animals, have always claimed from the physi- 
cian a large share of attention. In proportion also as the knowledge of healthy 
anatomy and physiology has become extended, so has pathology and morbid 
anatomy gradually but steadily acquired an important and prominent position 
among those branches of study on which Medicine rests its claims as a science. 

Morbid Anatomy is a department of medical science which has gradually 
grown out of the accumulated experience and observation of ages; but 
Pathological Histology, as a science, is of modern origin. It is but yet 
in process of development, although, its foundations may be traced in the works 
of the earliest medical writers of antiquity. All of them refer to changes 
which they merely supposed had taken place in the internal organs ; and they 
were doubtless led to this assumption by observing the connection that existed 
between structural lesions of the external parts and their accompanying symp- 
toms. Hippocrates describes the deposit of tubercles in the lungs, the symp- 
toms occasioned by them in a crude state, and those which attend their soft- 
ening and discharge. 

The science of Morbid Anatomy is a record of facts. In its relation to 
the progress of Medicine it is a living record — a history whose pages must be 
ever open to receive the observations which are constantly being made by 
those engaged in pathological pursuits — a record from which one may ascer- 
tain at any time the conditions under which morbid changes or new forma- 
tions in the body have taken place. The pages of this history show that at 
the present day the department of pathology is in a transition state ; and the 
position of Medicine, as a science, must eventually result from a rearrange- 
ment of the innumerable details which the sciences of morbid anatomy and 
histology may disclose and unfold. It is necessary, therefore, and often advan- 



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56 TOPICS RELATIVE TO PATHOLOGY. 

tageous, to look back upon the past, and see 'what has already been done, so 
that its venerable facts may not be lost sight of, but grouped in series with the 
extensively verified experiments and observations, of the present day. In so 
doing, if we pause and contemplate the steps which have been taken to arrive 
at our present position, such a contemplation may stimulate the youthful 
student to the noblest exertions of his intellect, as he cannot fail, with exten- 
sive study, to see before him, and on every side, much unlabored but produc- 
tive soil. Such a retrospect will at the same time have the effect of placing 
in a prominent aspect the varied influences which Morbid Anatomy has had 
on the Science of Medicine, the conditions under which it has flourished, and 
the legitimate objects of its investigations. 

The art of printing had not been long invented when books on morbid an- 
atomy began to issue from the press ; and although the early period of the 
fifteenth century has left little enduring literature of any kind (but has been 
mainly distinguished by the number of colleges then founded), yet about this 
time pathological anatomy in the medical school of Florence shows the earliest 
evidences of an existence. 

The facilities for study which the art of printing introduced soon stirred up 
ardent students ; and the sixteenth and seventeenth centuries produced much 
that will ever remain famous in the annals of medical science. Eustachius, 
Tulpius, Ruysch, Harvey, Malpighii, and Leuwenhoeck are names familiar 
as household words to the student of Medicine. The earlier attempts of this 
period to form a system of pathological anatomy are characterized by abortive 
endeavors to explain all results upon some exclusive and general principle. 
A spirit of speculation marks the character of the age. The men of that time 
had observed but few facts ; and on these facts they preferred to speculate 
and dogmatize, rather than prosecute the further interpretation of nature, or 
record more observations. Accordingly, theories in abundance successively 
led captive the minds of the medical world, and, disappearing one after the 
other, demonstrated the unstable foundations on which the science of Medicine 
had been placed. The leader of each sect founded his so-called school or 
system, all of them distinguished by a due amount of arrogance and con- 
tempt for predecessors and contemporaries — a feeling unhappily not yet quite 
extinct. The " vital agency," the " influence of the himiors," and of the " solid 
organs," have each been considered by turns as the only orthodox belief; and 
each has had their school and sect respectively designated as the Vitalists, the 
Hwnoralists, and the Solidists. The theories of Galen, of Paracelsus, and 
others, have all been famous in their time, but are now unheard of, and 
almost unknown. The same fate awaits the false theories and absurd con- 
ceits of more recent times, although, as in the case of Stahl, Cullen, Brown, 
and Broussais, they have had a wide prevalence in the schools of Europe, 
and made impressions on the sentiments of the profession which yet influ- 
ence their modes of practice and the reasons of their belief Broussaisism, 
Hahnemanmsni, and some other systems, "the fruits of a luxuriant fancy 
and of few facts," must all descend, as others have done, the same inev- 
itable slope to oblivion ; but the vast collection of facts which the founders 
and followers of such systems eventually accumulate and bring to notice, 
remain unchangeable, and will continue to recur in the daily experience of 
our profession, just as they appeared to the venerable fathers of medicine 
centuries before the Christian era. The practice of medicine, as based upon 
rational principles and a knowledge of the nature of diseases, has thus oscil- 
lated through these varied systems and innumerable theories, and the science 
of Morbid Anatomy has been marked throughout by unmistakable periods of 
progress, of stationary existence, or even of retrogression, according as one or 
other exclusive system had the ascendency, or as each principle or theory of 
practice challenged for itself a supreme importance. 

The modern doctrines relative to the nature of diseases and the practice of 



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PHYSIOLOGY THE BASIS OF PATHOLOGY. 57 

Medicine are guided by the dictates of Physiology, and of what is known 
regarding the development and growth of the human body. Ordinary dissec- 
tions alone, or post-mortem examinations of the body, have long since ceased 
to furnish us with facts before unknown ; and new modes of extending obser- 
vation and research, by taking advantage of every physical aid to the senses, 
are diligently looked for by the modern anatomist, physiologist, and physi- 
cian ; and the means and instruments which advance the science of physiology 
are well able to advance our knowledge regarding the nature of disease- 
processes. 

A belief is now rapidly gaining ground, and acquiring a hold on the pop- 
ular mind, that advances in the science of Medicine in future years will be 
mainly due to a better appreciation of the causes of disease ; and just in propor- 
tion as our knowledge of physiology and pathology becomes more exact and 
extended, so will the causes of disease be appreciated, and the occurreiice of disease 
on a large scale prevented. An amiable and large-minded physician, the late 
Sir John Forbes, emphatically recorded the observation, more than twenty 
years ago, that " here the surest and most glorious triumphs of medical science 
are achieving, and are to be achieved." He himself lived to see great and good 
results ; to see improvements in social and sanitary matters which continue 
to be realized, and whose rapid progress is characteristic of the present period. 
Within the last half century laud-draining and town-sewering have ripened 
into sciences. From rude beginnings, insignificant in extent, and often in- 
jurious in the first instance, the systematic sewering of towns and draining of 
land have become of the first importance. Land has thus, in not a few in- 
stances, doubled its value. Town-sewering, with other social regulations, have 
contributed to prolong human life from 5 to 60 per cent, as compared with 
previous rates in the same district. Agues and typhoid fevers are reduced in 
the frequency of their occurrence. Since 1840 an annual mortality in English 
towns of 44 in 1000 has been reduced to 27 ; an annual mortality of 30 has 
been reduced to 20, and even as low as 15. Not less remarkable reductions 
have taken place in the mortality and loss of strength in the army and navy ; 
so that generally it may be said that human life has now more value in Eng- 
land than in any other country in the world — a result entirely due to better 
sanitary arrangements (Rawlinson " On Sewering of Towns," 8oc. of Arts 
Journal; vol. x, p. 276). 

The political economist, therefore, cannot now regard Medicine in any 
other light than as a productive art ; and the labors of the physician, whether 
in civil or in military life, cannot be regarded as unproductive labor. 

But the science of Physiology (on which much of our sanitary improve- 
ments are based) has immeasurably outstripped the science of Pathology in 
the comprehensiveness of its views and in the value of its results ; while Pa- 
thology, in its turn again, has always been, and ought to be, in advance of 
Therapeutics. The best physiologists have distinctly recognized that the basis 
of their science must include not only a knowledge of animals below man, 
but a knowledge of the entire vegetable kingdom. Without such an exten- 
sive survey of the whole realm of organic nature, we cannot possibly under- 
stand human physiology, and far less comparative physiology. The science 
of Pathology, therefore (whose aim is to expound the nature of all diseases), 
must be, a fortiori, very far behind Physiology. The diseases of the lower 
animals, for instance, rarely form any part of the study of the student of 
Medicine. The diseases of plants are almost entirely neglected. Yet it is clear 
that until all these have been studied, and some steps taken to generalize the 
results, every conclusion in pathology regarding the nature of diseases must 
be the result of a limited experience from a limited field of observation. How 
do we know that the blights of plants, or the causes of them, are not commu- 
nicable to animals and to man? We know how intimately related the dis- 
eases of man and animals are with famines and unwholesome food ; and of 



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58 TOPICS RELATIVE TO PATHOLOGY. 

famines with the diseases of vegetable and animal life, as much as with the 
destruction and loss of food. 

To Physiology, therefore, in its most comprehensive sense, and to a knowl- 
edge of the natural and normal development of animal and vegetable beings, 
we must look for future progress in pathology ; while the means and instru- 
ments which advance physiology will simultaneouly advance our knowledge 
regarding the nature oj diseases — a sound knowledge of which can alone enable 
us to " appreciate their causes," and so arrange measures for tlie prevention of 
many of them, based on the great truths of science. 

Organic chemistry, the microscope, the ophthalmoscope, the sphygmograph, the 
laryngoscope, and such-like instruments, have opened up new fields of labor, 
which are being diligently cultivated ; and while alterations in the ultimate 
tissues and organs are more especially attended to, the first beginnings of dis- 
ease, the development of new formations, and the examination of excretions, 
and of specific products, claim a large share of attention. 

Histology, or the study of the development and arrangement of the tissues 
in the formation of normal and healthy organs, is characteristic of the ana- 
tomical investigations of the present day ; while the histology of morbid prod- 
ucts and chemico-physiological investigation into the nature of morbid 
changes is characteristic of the pursuits of- the science of modern Pathologi- 
cal Anatomy. 

It is also a significant fact that now, in the nineteenth century, some of the 
leading doctrines of the humoral pathology which prevailed in the seventeenth 
are again revived. The experience and learning of that erudite period are 
now being made available for modern uses. By the improved means, instru- 
ments, and methods of research of modern times, important truths may be 
sifted from the errors and theories with which they are mixed up in the 
ancient chronicles of medical science ; and when we get analogous conditions 
of disease with which the phenomena described by the ancients may be com- 
pared, " not a few of the apparently modern beliefs are daily found to have a 
time-honored reputation unappreciated before." 

The chemist and the histologist now combine their researches, and, working 
hand in hand, we regard them as the most inquisitive anatomists of the time. 
They lend assistance of the most important kind in laying the foundation of 
our knowledge regarding the nature of diseases, the details of which can only 
be made more certain and perfect by taking advantage of every kind of scien- 
tific knowledge which can be brought to bear upon medical research, and 
more especially, — (1.) By physical aids to the senses, extending our means 
for the actual inspection and appreciation of phenomena. The use of the 
thermometer, the sphygmograph, microscope, ophthalmoscope, laryngoscope, 
the stethoscope, and specula of various kinds, aided by a careful study of the 
writings and labors of the men who have more particularly devoted their 
attention to observations by such means, may be quoted as examples (Laen- 
NEC, Louis, Walsh, Stokes, Hope, Bennett, Quekett, Viechow, Wun- 
DEELicH, Traube, Vogel, ]3eale, Graefe, Czeemak, and others). (2.) 
By the knowledge (gradually being made more extensive) of the textures, 
organs, and functions of the body, whose normal exercise constitutes a healthy 
existence (Longet, Mullee, Shaepey, Valentin, Allen Thomson, Cae- 
PENTEE, KiEKEs, Paget, Kollikee). (3.) By an intimate knowledge of 
the normal development of the human textures, as well as those of plants and 
animals from the fecundated ovum (Bischoff, Costa, Allen Thomson, 
Huxley, Newpoet, and Kollikee). (4.) Besides these kinds of mvestiga- 
tions, the science of practical medicine has been, and is being, advanced by 
operations and experiments upon the internal organs of living animals, oppro- 
briously termed vivisections. At some of our great schools of medicine such 
investigations are now being actively but judiciously prosecuted and taught. 

Successful inquiries into Pathology, or the nature of diseases, cannot be said 

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HOW THE SCIENCE OF PATHOLOGY HAS BEEN ADVANCED. 59 

to have commenced till the middle of the eighteenth century, when the great 
work of Morgagni issued from the press. It was the work of his lifetime. In 
the eightieth year of his age, and not till then, did he consider himself war- 
ranted to publish his observations, De Sedibus et Causis Morborum (1761); a 
work whose material and circumstances of publication read us the practical 
lesson, that the more frequently a disease occurs, the more necessary it is that 
its phenomena should be carefully mvestigated. And when we think of the 
prudent reserve, the anxious and the conscientious delay exhibited by Har- 
vey, Morgagni, and Jenner, in the publication of their respective researches, 
we cannot but contrast the circumstances with those under which the exuber- 
ance of medical publications are now given to the world. Morgagni modified 
and corrected many of thcviews entertained and promulgated by his prede- 
cessors ; and the study of the nature of diseases was carried into the com- 
mencement of the present century by Cullen, De Haen, William and John 
Hunter, Poetall, and Bichat. 

Our knowledge regarding the nature of disease-processes has advanced 
simultaneously with that ot general anatomy; and when the component parts 
of an organ, and of the human body, came to be distinguished, it was observed 
that membranes and tissues might be individually diseased, while neighboring 
membranes and tissues remained untouched. Bichat's idea, therefore, of de- 
composing the animal body into its elementary parts, must be regarded as 
the foundation of modern special pathology, and Morbid Anatomy. He 
pointed out the necessity of studying diseases with reference to the different 
tissues as separately and specially affected ; and it has been since shown, in a 
remarkable manner, how general anatomy, deduced from the physical proper- 
ties of parts and crude observation, may coincide with more minute investiga- 
tions of a chemical and microscopical kind. The membranes and tissues of 
the human body, roughly torn asunder by Bichat, are now themselves being 
daily subjected to a more inquisitive analysis of an anatomical and chemical 
nature, which unravels them into still more minute histological elements. 

Although, therefore, Bichat entertained the view that .each tissue had its 
own diathesis, it is to Cullen and the Hunters, in this country more especially, 
that the application of the distinction of tissues was made to illustrate the 
nature of disease-processes. 

Cullen's descriptions of diseases are descriptions of groups of phenomena 
which comprise complex morbid states. 

The written labors of the Hunters form but a small part of the memorials 
of what they did to elucidate the nature of diseases, and it is only those who 
have had the opportunity of carefully examining their museums, preserved in 
London and in Glasgow, that are able to form any conception of the compre- 
hensive nature of their labors, or to assign to them a proper place among 
those who have successfully advanced the science of Medicine. They hold a 
position in science at least one hundred years in advance of the age in which 
they lived. 

Bichat, Cullen, and the Hunters, in their respective countries, have thus 
reciprocally influenced and advanced the progress of our knowledge regarding 
the nature of diseases. And although it was reserved for Bichat to complete 
a more perfect system of general anatomy, it must not be forgotten that Dr. 
Carmichael Smith, in 1790, applied his knowledge of textural anatomy to 
elucidate the nature of disease-processes ; and that Pinel, after him, in his 
NosograpUe Philosophique, made the distinction between the membranous and 
other animal structures the foundation of his pathology. The classic work of 
Baillie (his Morbid Anatomy), published in 1793, closed the labors of the past 
century. 

If we look now to the tendency of the studies and researches of those men 
just named, including Bichat, the truth gradually asserts itself, that it was 
necessary to study alterations of structure so as to connect morbid changes 

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60 TOPICS KBLATIVB TO PATHOLOGY. 

with the symptoms of diseases during life, and with the operations of ascer- 
tained causes of morbid action. The nature of the morbid changes was ob- 
sei-ved to be more apparent in the progress of external diseases ; and, therefore, 
surgical experience was brought to bear upon the elucidation of internal dis- 
ease-processes. One especially marked result of this nature is to be seen in 
the modern application of the ophthalmoscope, which reveals information the 
most important, for the diagnosis of many general diseases, from an examina- 
tion of the interior of the eye. 

Thus the progress of Morbid Anatomy is, in a great measure, a record of 
the history of Medicine ; and we can trace the science of special morbid anat- 
omy, giving a character to the various systems of the healing art which have 
prevailed from time to time. 

All the writers up to the time of Bichat, Laennec, and Abercrombie, were 
pure morbid anatomists, who did not connect the effects of disease with their 
causes, and who recognized the changes of disease as important only in pro- 
portion to their magnitude as apparent to the senses. They are, therefore, 
regarded as pure solidists, whose researches doubtless contributed much towards 
a correct knowledge of the changes in the organs of the body, while the con- 
dition of the fluids was neglected, as well as the relations of the textures, 
organs, and fluids, in the combined exercise of their functions. Simple func- 
tional disturbances were thus wholly overlooked, and the constitutional con- 
nection of local afiections entirely lost sight of 

The contemporaneous surgery of the period previous to Bichat was marked 
by its unwillingness to recognize anything but material facts, mechanical 
processes, and contrivances. The surgeons of those days desired to know 
nothing but anatomy and mechanics; and, accordingly, it may be recognized 
as the period of pure anatomical and mechanical surgery, distinguished by 
the writings of men whose works bear ample testimony that the surgery of 
the period was founded on exact and even minute anatomical knowledge. 
No allusion is made, however, by them to medicine, — ^they make no applica- 
tion of physiological truths, and they encourage no therapeutic tendency apart 
from mechanical or instrumental interference. 

The purely solidist, as well as the purely humoral principles by which the 
nature of diseases have been explained, may be said to have died a natural 
death long ago ; but, as already noticed, the remembrance of what is valuable 
in the results of both are preserved in modem pathology, which takes its 
stand upon anatomical and physiological facts, connected by simple methods 
of inductive observation with the symptoms and signs of disease as seen and 
expounded to the student by the distinguished professors of Clinical Medicine 
and Surgery at most of our celebrated schools, where clinical instruction is 
given. 

In this field of instruction it would be invidious to mention here the names 
of men still living. For their own sakes, as well as for science, may they be 
long deprived of being thus honorably and respectfully mentioned. As teach- 
ers, they are in our own country familiar to every student. As recorders of 
what they observe at the bedside and in the post-mortem room, they are not 
less celebrated abroad than appreciated at home. 

Tested by extensive clinical observations, the character of the present period 
in the history of Practical Medicine is one of probation as well as of progress, 
marked by a close inductive examination of past generalization and classifica- 
tion of facts, however remotely connected, which illustrate the nature of dis- 
eases and their treatment. 

Side by side, since 1816 and 1819, the microscope and the stethoscope have 
advanced our knowledge of the nature of diseases with a regular and accele- 
rated velocity ; but they have only done so as assistants and in subordination 
to laws and facts whose knowledge we have acquired, by a close observation 
of general symptoms, of which such instruments have never been intended to 

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CHARACTERISTICS OF MEDICAL RESEARCH. 61 

take precedence. They have never accomplished, nor can they ever accom- 
plish, useful practical results, to the exclusion of such other methods of obser- 
vation as have just been noticed. We are not to confound relative smallness 
with absolute simplicity, and believe that because a simple organic cell is a 
small object — ^because we can see around it, through it, and on every side of 
it — the lunctions and conditions of its existence are less complex or less obscure 
on that account than are those of a more large and complex organ, or the 
functions of a living body. 

We are not to suppose that because the stethoscope enables us to detect a 
mitral murmur, or a crepitation in a lung, we are justified at once in adopting 
one, and only one, method of treatment. It is this exclusive use of instru- 
ments, to the disregard of general symptoms and signs of disease, derived from 
close observation and knowledge of the living functions, which leads to the 
repudiation of the use of such instruments by the sagacious and experienced 
physician, who sees the numerous errors not unfrequently committed by his 
younger brethren, who trust too exclusively to instruments in the diagnosis of 
disease. 

Like the stethoscope, the microscope has been unjustly and unnecessarily 
burdened with labor, and has been equally unjustly blamed, and brought into 
unmerited discredit, when it has failed to elucidate the nature or even pres- 
ence of a morbid state, the existence of which could not be doubted, but which 
the sense of sight could not appreciate, even when presented in small quanti- 
ties greatly magnified. In such instances the microscope has been applied to 
uses which it was not the nature or province of the instrument to detect. 
The gravimeter or hydrostatic balance, the microscope, the stethoscope, the 
ophthalmoscope, the laryngoscope, the pleximeter, the sphygmograph, and the 
thermometer, are merely instruments of pathological inquiry, each one adapted 
for the determination of particular classes of facts. They can only elucidate 
disease when they are brought to bear upon physical properties, the nature of 
which they are able to appreciate ; and it is only from their combined and 
appropriate use, in connection with a history of the general signs and symp- 
toms of disease in each particular case, that our knowledge of the nature of 
diseases will be advanced. 

The industrious employment of these aids to diagnosis, and an intimate 
acquaintance with the results, are attended with this further advantage, that 
such practice and knowledge enable their possessor to appreciate the general 
symptoms of disease with infinitely greater certainty than heretofore. This is 
the usual consequence of training in all exact methods of observation. The 
thorough study of these aids to the senses in appreciating disease leads directly 
to the possibility of dispensing with them in many instances. By means of 
auscultation and percussion, for example, our attention has been drawn to 
numerous conditions of the thorax, which enable us to make the diagnosis at 
the first glance, which hitherto was not possible ; because the conditions for 
diagnosis could never have been recognized without such physical aid to the 
senses as that derived from auscultation and percussion. In many cases, from 
the mere inspection of a patient, a well-instructed clinical student may decide 
upon the existence oi pleurisy, pneumothorax, emphysema, or pulmonary tubercle. 
The initiated are thus frequently enabled to dispense with percussion and 
auscultation ; but if they had never acquired the practical knowledge of the 
subject — ^if they had never examined numerous patients by means of these 
instruments as physical aids to diagnosis — and so learned thus to determine 
with great exactness the significance of the various forms and movements 
exhibited by the thorax, they would never have been able to appreciate their 
significance. So, also, the physician well instructed in the use of the ther- 
mometer may, in hundreds of cases, without its aid, draw conclusions with great 
certainty, incomprehensible to others not so instructed ; but if, led away by 
this skilfulness, he is induced to dispense with exact thermometrical control. 

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62 TOPICS EBLATIVE TO PATHOLOGY. 

he may soon fall into gross errors. So it is with the ophthalmoscope, sphyg- 
mograph, specula, and all other more or less exact physical aids to diagnosis. 
Let them be in constant and appropriate use, but the results must always be 
taken and compared in connection with other general symptoms of disease. _ 

In all the temperate regions of the world, histology, as applied to morbid 
products, has been cultivated, and has advanced our knowledge regarding 
disease ever since 1838. In warmer latitudes our knowledge of practical 
Medicine has been advanced by extensive observations on physical climate, 
medical topography, and by organic chemical analysis applied to obtain thera- 
peutic agents from the vegetable world. Those may be said to be the charac- 
teristics of the researches of our own country, Germany, France, and America, 
as contrasted with the nature of the observations mostly prosecuted in India. 

No exclusive doctrine will now stand the test of well-directed pathological 
inquiry, the main object of which is to connect all organic changes (lesions) 
and functional derangements, with their symptoms and causes, with the view 
of applying rational remedies and prophylactics. The too exclusive study of 
pure organic pathology and morbid anatomy leads to no distinction between 
the signs and causes of disease ; and the obvious tendency of such exclusive 
study is to exaggerate the importance of the principles it may establish, to 
hold out no hopes of cure, and to undervalue the power of remedies and 
remedial measures. To obviate this tendency, it is necessary to have recourse 
to inductive reasoning, so as to connect all the morbid changes seen or appre- 
ciated after death with the signs and symptoms of disease observed during 
life. Thus it is that links in the chain of disease-processes which, from a 
one-sided or exclusive view, appear isolated and localized, are really found to 
be connected with each other. It may be, also, that they are connected with 
a long but intelligible series of processes developed during life through the 
metamorphosis of tissue, and going on in apparent health, or in an obviously 
morbid exercise of fiinction. The constitutional origin of many local diseases, 
otherwise inexplicable, then becomes apparent. 

Among the more eminent exponents of this rational school of pathology, 
who at an early period in this country discerned and appreciated such doc- 
trines, we find the names of Allen, Golding Bird, Sie Robert Carswell, 
Gregory, Hope, Hodgkin, Marshall Hall, Prout, William Stark, 
John Thomson, Tweedy Todd, and many others, who, although now no 
more, have left behind them imperishable evidence of their labors. The 
younger pathologists of the present day, whose name is Legion, follow in the 
footsteps of these men, extending the fields of observation and the boundaries 
of the science of Medicine. By them the importance of morbid anatomy is 
suificiently appreciated, and its province distinctly defined and limited as 
follows, namely: (1.) To detect the "stamps of disease," or the changes 
which have taken place during the course of diseases in the structure of tissues 
and organs of the body ; (2.) To demonstrate the exact seat of these " stamps 
of disease," or local alterations which have become established during the 
progress of disease. 

The investigation and elucidation of the nature, course, and causes of those 
changes, constitute the prominent objects of the science of pathology. By 
the aid of clinical observation during life, and morbid anatomy after the 
death of the body, pathology seeks to establish the relations of the changes 
which lead to the lesions, and so to connect the general progress of disease 
with its symptoms and signs. 

Morbid Anatomy goes beyond its province when it attempts to point out 
the nature of the proximate cause of disease. It is only by the application 
of inductive reasoning that the connections of causes and morbid effects can 
be shown, and such constitutes the main object, and is the highest aim, of the 
science of Pathology. 

The morbid anatomist finds a lesion or change for what ought to be the 



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FORMS OF THB CONSTITUENT ELEMENTS OF DISEASE. 63 

natural structure, appearance, or condition of a part. The pathologist seeks 
to connect such lesions with signs and symptoms during life, that the practical 
physician may suggest a remedy to the disease, and that the nosologist may give 
it a name, distinguishing characters, and a place in his classification. 



CHAPTER VII. 



THE ELEMENTARY CONSTITUENTS OF LESIONS AS SHOWN BY MOEBID 
ANATOMY AND OTHER MEANS OF RESEARCH. 

Where the material effects or "stamps" of disease can be rendered obvious, 
they are found to consist, for the most part, of — ■ 

1. Morphological changes in the elementary textures of the body generally, 
and altered conditions of the fluids. 

2. The presence of new formations foreign to the normal condition of an 
organ or system of organs. 

3. Change in the position or form of some of the organs or parts of organs. 

4. Deposits within or surrounding the elements of tissues, or changes of a 
degenerative or retrograde kind in them. 

The object of prosecuting the anatomy of disease is, therefore, in the first 
instance, to institute a comparison between the known appearances or standard 
of health, and an altered state of the parts as evidence of disease. Such a 
comparison is, in the first instance, founded on an intimate knowledge of the 
doctrines stated at p. 56. 

Means and Instruments of Eesearch. — To institute investigations such as 
those indicated at p. 61, advantage must be taken of almost every branch of 
human knowledge. The methods of carrying on pathological research are 
therefore extremely varied, but may be shortly enumerated under the follow- 
ing heads : 

1. The opening of dead bodies, to ascertain the condition of their organs 
and tissues in all that relates to their structural, chemical, and physical prop- 
erties (ROKITANSKY, HaSSE, ViRCHOW). 

2. Application of various instruments, such as the microscope, and of means 
to ascertain the absolute and specific weight of organs or parts, the relations, 
size, form, and colors of structures, and the like (Quekett, Bennett, BealE, 
Peacock, Boyd). 

3. Application of chemical investigations to the diseased products (Vogel, 
Simon, Day, Lebeet, Gluge, Beale, Gareod, Christison, Parkes, Vir- 
CHOw, Frerichs, Gairdner). 

4. Application of statistics to determine various points of interest in refer- 
ence to the nature, course, and complications of diseases (Wm. Fare, Guy). 

5. Means to preserve objects for further study by the microscope, or any 
other mode of examination (Tulk, Henfrey, Beale, Quekett, Van dee 

KOLK, LOCKHART ClARKE). 

6. Experiments instituted on living animals, and, in certain cases, on man, 
with the view of artificially producing a morbid condition. A careful study 
of such experiments by the previously mentioned "means affords valuable in- 
formation, for the causes in action are more under control than those which 
are spontaneously brought about by disease in the living body (Beenaed, 
Harley, Pavy, Kuchenmeister, Zenker, and others). 

The immediate object of such investigations is to obtain information re- 
garding the material changes in the different parts of the body which accom- 
pany or produce morbid symptoms, and to connect these changes with symp- 

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64 TOPICS RELATIVE TO PATHOLOGY. 

toms and signs of disease during life. We thus learn how morbid products 
are formed at first and gradually perfected ; and by combining these two kinds 
of knowledge we learn the relative connection of two orders of phenomena — 
namely, how the perverted properties, disordered actions, or altered structures 
give rise to perverted or impaired secretions ; disordered and irregular motions ; 
deranged, impeded, or interrupted functions. In other words, the "order of 
invasion of disease-processes " is learned from such investigations ; and we are 
thereby taught how parts, once the seat of morbid change, return by various pro- 
cesses of nutrition, growth, repair, or reproduction, to their normal condition. 

The questions arising out of such investigations are, or ought to be, the first 
object of thought to the conscientious medical practitioner. It is his duty, from 
an attentive consideration of the signs and symptoms of disease, to form an 
idea, as accurate as possible, of the nature aijd extent of the morbid action or 
change which is going on, or which may be set up, in the tissues, organs, and 
fluids of the living body. 

If, therefore, he does not avail himself of every means and instrument by 
which he can ascertain the existence of change in the dead body, and its 
alteration from some standard of health — if he does not, embrace every oppor- 
tunity of making post-mortem examinations — ^if he contents himself merely 
with observing signs or symptoms of disease, without witnessing the changes 
of structure, if any, which may give rise to them — he can have little conscious 
satisfaction in the study of Medicine as a science, or in the practice of the 
healing art. In the words of Cruveilhier, he will, during his lifetime, "see 
many patients, but few diseases." Such a practitioner is not to be trusted. 

Forms of the Constituent Elements of Disease. — The histologist has now 
ascertained the various simple organic forms which compose the textures in 
their normal state, and the mode in which these textures are arranged and 
combined so as to form the organs and systems which carry on the healthy 
functions of the body. The pathologist has made out (although with less 
completeness), by the methods of observation and experiment already indi- 
cated, the various simple organic forms which constitute the elements of those 
material changes whose phenomena of growth, decay, and varied change are 
associated with the manifestations of disease. By classifying and arranging 
these forms, we obtain more or less clear ideas of lesions ; and we ascertain 
that the, morbid processes follow, in their development, a very definite order 
of change, but not yet determined with absolute certainty in each disease. 

An anatomical investigation of morbid parts, conducted with the aid of the 
microscope and other instruments of research, shows that the material of which 
their substance is made up is of very various structure, sometimes combined in 
forms of one kind throughout, and sometimes varied by the development and 
combination of many elementary forms, more or less solid, soft, or fluid. 

An analysis of the morbid material, carried as far as scientific means at 
present enable us, shows that the elementary conditions in which morbid prod- 
ucts are found may be described as follows : 

1. Fluid matter and hyaline substance, more or less soft, soluble, and prob- 
ably nutrient to surrounding or imbedded morbid elements. 

2. Simple elementary forms of the nature of deposits, sometimes of a min- 
eral or inorganic character: e. g. (a) amorphous granules; (6) crystalline 

-Structures in a granular state. 

3. Simple, but organized products (minute rounded particles, nuclei, or 
germinal matter) capable of growth, i. e., which live, change, convert or ger- 
minate : e. g. (a) amorphous masses (plasm gernis, bioplasm, protoplasm) ; (6) 
nuclei or granules ; (e) compound corpuscles ; (d) simple cells ; (e) fibres. 

The various appearances and conditions which these simple forms may 
assume in disease, as well as the functional states with which they are fre- 
quently associated, lead to a further enumeration and classification of morbid 
elementary products, as well as of more complex disease-processes, as below: 



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MORBID ELEMENTARY PRODUCTS. 65 



A. — MoBBiD Elementary \Peoducts. 

I. Exudations more or less soft, semi-fluid, or fluid, and formed 
OF, — 

a. Germinal, plastic, and formed material, wliich has sometimes been called 
blastema, plasma, bioplasm, protoplasm, coagulable lymph, false membrane, or 
fibrin, as seen adhering to free surfaces. 

b. Aqueous matter, as seen in the morbid state termed "dropsy," and 
"mdema," of parts. 

e. Gaseous exudations, as seen in the variuus forms of pneumatosis; e. g., 
emphysema, flatulency, tympanites, pneumothorax. 

II. Exudations more or less consolidated, and consisting of, — 

a. Molecular or granular material, from the 800th of a line to an immeas- 
urably small size, and consisting chiefly of the simple forms of, — 

(1.) Forms of an organic kind capable of growth, which live, grow, con- 
vert, or germinate, and invariably take origin from a pre-existing structure, 
(bioplasm, protoplasm, &c.) 

(2.) Fatty molecules or granules. 

(3.) Deposits of an inorganic kind, generally calcareous salts. 

(4.) Pigment granules. 

b. Coagulable compounds, resisting the action of most reagents, such as are 
seen in the elements of tubercle, scrofula, oleo-albuminous formations, lardaceous 
degenerations. 

c. Exudations of a transitional nature, organized, which are capable of 
growth, which may become vascular, which grow from pre-existing structures, 
and which are composed of, — 

(1.) Consolidated homogeneous material, passing to 

(2.) A fibrinoid arrangement of the molecular or granular particles com- 
posing connective substance, and a subsequent formation of fibres in it or 
from it. 

(3.) The formation of pyoid cells, and fibro-plastic or connective tissue 
cells, passing into fiisiform cells and fibres as the material becomes consoli- 
dated. 

(4.) The formation or exudation of fluid matter holding pus, or other more 
compound cells. 

III. Growths and Exudations of a specific kind. 

a. Lymph of small-pox and cow-pox, just removed from the vesicle, con- 
tains a great number of extremely minute particles. To these the active prop- 
erties of the lymph are entirely and solely due (Beale). 

b. Matter of glanders, of malignant pustule, and of the plague, contain 
similar particles. 

c. Fluid of infecting chancre, and of some forms of secondary syphilitic 
lesions, containing multitudes of living particles. 

d. Material of tubercle and scrofula. (?) 

e. Material of cancer. 

/. The growth in Peyer's glands during typhoid fever. 

g. The growth in Peyer's glands in cases of cholera. 

h. Melanotic or pigmentary germs. 

The minute elements of all of these resemble »each other so much in their 
microscopic appearances, that they cannot be distinguished from each other, 
or from pus ; and pus containing speciflc contagious properties cannot be dis- 
tinguished from ordinary pus, except in the matter of vital power or virulent 
specific properties, as evinced by its effects. The experiments and observa- 
tions of Dr. Burdon Sanderson tend to show that the specific material of each 
of these diseases consists of living germs ; and many there are who now believe 

VOL. I. ° 

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66 TOPICS RELATIVE TO PATHOLOGY, 

that the day is not far distant when we shall be able to demonstrate the 
material poison of each specific disease, just as the chemist is able to show the 
active principle of substances like opium, cinchona, and the like. 

IV. Material of a complex kind. 

a. Media of repair and reproduction of injured or lost parts — substance of 
granulations and cicatrices. 

b. Hypertrophy of parts. 

m (innocent. 

c. iumors, { ,. 

' ( malignant. 

d. Concretions. 

V. Parasitic Formations. 

B. — Complex Vital Morbid Processes whose Phenomena, more or 

LESS COMBINED, CONSTITUTE DISEASE. 

1. Catarrh. 

2. Inflammation, comprehending the following forms : 

(a.) Ulcerative. 
(b.) Suppurative. 
(c.) Plastic. 
(d.) Rheumatic. 
(e.) Gouty. 
(f.) Pycemic. 
(g.) Syphilitic. 
(h.) Scrofulous. 
(i.) Gonorrhoeal. 

3. Gangrene. 

4. Passive congestion. 

5. Extravasation of blood — Hemorrhage. 

6. Dropsy. 

7. Fibrinous deposit. 

8. Alteration of dimensions. 

(a.) Dilatation. 
(b.) Contraction. 
(c.) Hypertrophy. 
(d.) Atrophy. 

9. Degenerations. 

(a.) Fatty degeneration. ~) rri 

(b.) Mineral degeneration I ^'^^ components of atheroma and so- 

pr Petrifaction. ) called os«t/Jca<ioji. 

(c.) Pigment degeneration — Pigmentation. 
(d.) Fibroid degeneration. 
(e.) Lardaceous or albuminoid degeneration, lardaceous, waxy or amyloid 



10. Tumors, {"^^^Snant. 

i noiv-mahqnant. 

11. Cyst. 

12. Parasitic disease. 

13. Calculus and concretions. 

14. Malformation. 

15. Functional diseases. 

16. Fever. 



Such a classification as the above is merely intended to bring before the 
student at a glance the variety of morbid material which is concerned in the 
expression of many phenomena seen in the course of disease, the distinctions 
made being mainly based on structural analyses. 

While it is more prpperiy the province of the anatomist to describe the 



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PATHOLOGY AND ANATOMICAL CHARACTERS. 67 

MORBID ELEMENTARY PRODUCTS, it is the COMPLEX VITAL MORBID PROCESSES, 
WHOSE PHENOMENA, MORE OR LESS COMBINED, CONSTITUTE DISEASE, with 

which the Physician has more immediately to deal ; and these complex states 
require special notice in the following chapter. 



CHAPTER VIII. 

complex morbid states. 

Catarrh. 

Latin Eq., Catarrhus ; French Eq., Caiarrhe; German Eq., Catarrh; Italian Eq., 

Catarro. 

Definition — Engorgement of the bloodvessels of any region of the mucous 
membrane. ^ An abnormal secretion of fluid oozes out and flows from the surface. 
The tissue is succulent and sivollen ; and there is a copious generation or ■prolifer- 
ation of young cells, pushing their way to the surface, and so causing the flux. 

Pathology and Anatomical Characters The regions of the mucous tract 

most prone to catarrh are the nose, mouth, pharynx, larynx, bronchii, stomach, 
intestines, gall-ducts, urinary bladder, urethra (male and female), uterus, and 
vagina. These several regions give names to the catarrhal disease : e. g., 
acute or chronic bronchial catarrh ; virulent or non-virulent catarrh of the urethra ; 
uterine catarrh ; vaginal catarrh, and so on ; and these several forms of catarrh 
will be considered under the respective local diseases under which they are 
classified. 

A gradual flow of fluid secretion from the mucous surface is characteristic 
of catarrh, and hence the name. Under the microscope, numerous transpar- 
ent cells may be seen, called mucus-corpuscles, which are detached young 
epithelial cells from the deeper layers, or from the mucous glands. The sub- 
stance of the mucous tissue is swollen, moist, and flabby ; and the submucous 
tissue may become the seat of considerable serous infiltration (oedema), — a 
condition of great danger, when the mucous membrane of the larynx is in- 
volved. The redness of the membrane is sometimes diffuse, due to uniform 
injection of the bloodvessels ; sometimes mottled, when it is due to ecchy- 
mosis. The texture is softened so as to be easily torn. 

When the catarrh has become chronic, the evidence of this chronicity is 
seen in the extensive pigmentation of the mucous surface which has been so 
frequently implicated in the morbid process. It has a brownish color, from 
the pigment derived from oft-repeated ecchymosis in its substance. The sub- 
mucous tissue becomes thick, firm, and hypertrophied ; the bloodvessels, vari- 
cose and gorged with blood. The mucous secretion is now made up of an 
opaque, yellow-colored, tenacious substance, composed of cells indistinctly 
granulated, and containing divided nuclei — a " muco-purulent " secretion — 
where the mucus cannot be distinguished from the pus cell. 

The results of catarrh are seen in ulcerations, polypus growths from the 
long irritation of the surface, thickening and induration of the submucous 
tissues. 

There seems to be a certain predisposition, or structural development, of 
the individual, prone to catarrhal attacks. They are prone to occur in con- 
ditions characterized by poverty of blood and nutrition, in which the walls of 
the capillary vessels have a feeble power of resistance; while the tissues 
through which such vessels pass, are at the same time soft and yielding. The 
predisposition to catarrh is strongly marked in scrofula and rickets ; and, as 



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68 TOPICS KELATIVB TO PATHOLOaY. 

bronchial catarrh, the morbid condition is a frequent attendant on typhoid 
fever, measles, and small-pox. Effeminate habits also augment the liability 
to catarrhal affections. 

The first effect of catarrh is marked by an increase of the secretion of the 
mucus proper and normal to the part, — a peculiar viscid, ropy, pellucid sub- 
stance, without any visible corpuscles or organized particles. With an in- 
crease of this material there comes the mixture of epithelial particles from 
the mucous membrane, or corpuscles from the follicles and follicular glands 
imbedded in its substance. These particles vary in shape and properties ac- 
cording to the part of the mucous tract whence the catarrhal secretion flows ; 
and they increase in number from premature desquamation, while their char- 
acteristic local shapes are less and less perfectly preserved. With such in- 
crease of flow, there is afilux of blood to the part, and infiltration of its sub- 
stance with fluid material, making the membrane thick and spongy. It is 
swollen also by the increased production of the corpuscles which may arise 
from nuclear multiplication, both within the epithelial cells on the surface of 
the membrane, or within its follicles and in the corpuscles of the subepithelial 
connective tissue, for a greater or less depth, according to the degree of the 
irritation or inflammation in the part (Paget, Turnee, Kemak). These 
corpuscles are commonly called mucus-corpuscles ; and they differ only from 
the corpuscles formed from a serous membrane in a state of inflammation in 
the greater viscidity of the fluid in which they lie (Paget and Turner). 



iNFLAMMATIOIf. 

Latin Eq., Inflammation; French Eq. , Inflammation; German Eq., Eniiindung; 
Italian Eq., Inflammazione. 

Definition. — A complex morbid process characterized, — (1.) By a suspension 
of tlie concurrent exercise of function among the minute elements of the tissue in- 
volved ; (2.) By stagnation of the blood and abnormal adhesiveness of the blood- 
discs in the capillary vessels contiguous to the tissue-elements whose functions are 
suspended ; (3.) By contraction of the minute arteries leading to the capillaries of 
the affected part, with subsequent dilatation and paralysis of the contractile tissue 
of the affected bloodvessels. The nutritive changes between the blood and the 
minute component elements of the affected tissue become visibly altered, and if it 
persists, an appreciably excessive interstitial exudation infiltrates tJie affected tissue, 
with a constant tendency to a profusion of growth to which this interstitial exudor 
tion ministers abundant nutrition. This excessive exudation which foUoivs, as a 
result of the inflammatory state, is apt to be associated with an unhealthy condition 
of the blood, and of the blood-plasma, giving rise to varied forms of inflammation, 
and associated with varied forms of new growth, according to, — (1.) The elemen- 
tary structure in which it occurs; (2.) The spedfia, constitutional, or local disease 
with which this complex morbid process may coexist; arid (3.) According to the 
progress of the inflammation, the amount and suddenness of the effusion, the extent 
of tissue involved, the diminished vascularity, and the powers of absorption of the 
surrounding parts. 

Pathology. — As it is not possible clearly to define the limits of natural pro- 
cesses, it is not possible to give a correct definition of inflammation. It is a 
process the most important of all morbid states ; and a knowledge of its phe- 
nomena (at this very time — 1870 — undergoing an extensive reconsideration), 
the laws which regulate its course, and the relations which its several events 
bear to each other, have been always considered as " the keystone to medical 
and surgical science," and the " pivot upon which the medical philosophy of 
the time has revolved." 

It is not wonderful, therefore, that much has been written on the subject of 



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PATHOLOGY OF THE INFLAMMATORY PROCESS. 69 

inflammation, more especially since microscopic research has been brought to 
aid in the investigation of its phenomena. Among the many who have inves- 
tigated this morbid process with success, and by whose original observations 
its study may be said to have begun, the names of Wilson Philips, John 
Thomson, Gendrin, Kaltenbrunner, Gerber, and Miiller ; and more recently, 
those of Alison, Lebert, Gulliver, Addison, C. J. B. Williams, Bennett, W-har- 
ton Jones, Henle, Virchow, Paget, John Simon, Joseph Lister, Strieker, Cohn- 
heim, Prussak, and Recklinghausen, are well known ; and no account of in- 
flammation can be complete which does not embrace the results of the labors 
of these men. 

The early experiments which illustrate the nature and phenomena of inflam- 
mation have been made chiefly on the web of the frog's foot, and the folds of 
the frog's mesentery. The phenomena in both are found to correspond, in all 
essential points, with the results of experiments performed on the more or less 
transparent parts of warm-blooded animals ; such, for example, as the wings 
and ears of bats, the ears of rabbits, the mesenteries of these animals, the brains 
of rabbits and of pigeons, and the legs of dogs, upon the bones of which com- 
pound fractures have been inflicted. As a general result of such experiments 
and observations, it may be stated that the chief constituents of the inflam- 
mation-process are to be found in altered conditions of the healthy nutritive 
changes — the phenomena of the abnormal state becoming more or less obvious 
by the redness, swelling, heat, pain, impairment of function on a large scale, 
and sometimes exudation in the part aifected. 

Phenomena and Theory of the Inflammatory Process — The process of 
inflammation is one in which many stages of morbid action are passed through, 
and which reaches its acme when the serum of the blood and the liquor san- 
guinis, and even the corpuscles of the blood itself, transude or permeate the 
walls of the bloodvessels of the inflamed part, without rupture, into the sur- 
rounding texture. This has been termed " exudation." 

The series of complex changes through which the inflammatory process is 
seen to proceed, as observed in the transparent parts of animals under the 
microscope, are found to occur nearly in the following order : 1st. The beau- 
tiful experiments and observations of Mr. Joseph Lister, Professor of Clinical 
Surgery in the University of Edinburgh, clearly prove that a suspension of 
the concurrent exercises of function among the minute elements of the tissue 
involved is the primary lesion in the congestion of inflammation, and which 
immediately leads to — 2d. Inflammatory derangement of the blood, which, in 
the vicinity of the impaired tissue-elements, tends to assume the same charac- 
ters as blood always assumes when it is in contact with ordinary solid matter, 
and which renders it unfit for transmission through the bloodvessels. But a 
return of the tissue-elements to their usually active state will be associated 
with a restoration of the blood to the healthy characters which adapt it for 
circulation (Royal Society, June 18, 1857) ; and thus the normal essential re- 
quirements of blood and tissue mutually counterbalance each other. If blood 
is depraved, tissue must suffer; and if tissue is morbid, blood becomes morbid 
too, and may remain so if depuration is not completed. 3d. The arteries of the 
afffected part are narrowed, and the blood flows through them with greater rapid- 
ity. 4th. The same vessels subsequently become enlarged, and the current of 
blood is slower. 5th. The flow of blood becomes irregular. 6th. All motion of 
theblood ultimately ceases, and complete stagnation ensues. 7th, and lastly. The 
liquor sanguinis may be exuded through the walls of the bloodvessels; some- 
times accompanied by the exudation or permeation of blood-corpuscles. 

These different phenomena are associated with the production of the more 
obvious symptoms (and to some extent they physically account for them), 
namely, redness, pain, heat, and swelling. But although these changes are 
here mentioned consecutively, it is not to be understood that in every instance 
'of inflammation such changes can be traced in distinct succession. The 



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70 TOPICS RELATIVE TO PATHOLOGY.' 

changes, are to be studied as nearly aoncwn'ent, rather than as a distinct series 
of events, of which each stands in the relation of a consequent to one or more 
of its antecedents ; so that, starting from impaired function of the elements of 
tissue, to stagnation of blood in the capillary vessels, we must observe the 
various stages in the process almost as concurrent phenomena, which, for the 
purposes of study, are here enumerated in sequence. 

An analysis of these concurrent phenomena has shown that the conditions 
for the healthy nutrition of the part are materially changed, being somewhat 
as follows : 

I. The supply of blood to the part is altered, — (1.) By the changes in the 
bloodvessels, especially the narrowing of the arteries and subsequent enlarge- 
ment of the capillaries ; (2.) By the mode in which the blood moves through 
them. 

The narrowing of the arteries, in the first instance, may be demonstrated 
under the microscope, by the application of warm water simply to the web of 
the frog's foot ; and the same phenomena are presumed to occur in man, for 
the following reasons : Sudden operations of the mind, and the application 
of cold, produce paleness of the skin — an effect which can only arise from con- 
traction of the minute arteries, and the diminution of the quantity of blood 
thereby conveyed by them. The subsequent enlargement of the capillaries is 
presumed to be a constant event in the inflammation of a part. It usually 
extends to some distance around what may be considered as the chief seat, cen- 
tre, or focus of diseased action, but in some textures the enlargement and red- 
dening are peculiar to the vascular parts in the vicinity. To this condition of 
the blood and bloodvessels is to be ascribed the usually first observable symp- 
tom of inflammation in a part, namely, the redness. But there are also many 
circumstances under which inflammation has existed, and yet no redness is 
apparent in the part itself. We often find the cartilages of the joints ulcera- 
ted, and yet not a trace of a red vessel. In cases of bronchitis, with purulent 
expectoration, if the lungs be washed so as to remove the morbid product, the 
most experienced anatomist may be unable to determine whether the parts are 
in a state of health or disease. Take the arterial system, and how often do we 
find the aorta thickened and thinned, softened and indurated, vilcerated, and 
its elasticity entirely destroyed, and yet not a red vessel to be seen ; and when 
the patient has neither complained of the slightest sensation of pain, nor of 
any feeling of heat in the part during life ? A large abscess may form in the 
brain or areolar tissue, or pus may be effused into the cavity of the abdomen, 
without any appearance of redness, or even evidence of having been preceded 
by any suffering. Although in certain parts — extra- vascular tissues, as the 
cornea and the articular cartilages, and the arterial tissues — the previous 
existence of inflammatory, action is obvious from the effects produced, and 
where no bloodvessels existed obvious to the eye, assisted or not by the micro- 
scope, yet it is, for the most part, found that enlargement of the bloodvessels 
of the adjacent parts, and especially of those from which the diseased part 
derives its nutrient supply, is a constant phenomenon, purely functional, and 
which appears to be developed indirectly through the medium of the nervous 
system. In inflammation of the cornea, for instance, the bloodvessels of the 
sclerotic and conjunctivae are enlarged. In ulceration of the articular carti- 
lages, the surrounding synovial membrane and the articular extremities of the 
bones are more fully pervaded with enlarged bloodvessels. The vasa vasorum 
of the aorta round the morbidly thickened part are also the subject of enlarge- 
ment, and the channel of increased supply of blood, — a series of vascular 
changes ministering to the act of inflammation in each of these extra-vascular 
parts. There is, therefore, no doubt that the conditions favorable to the exist- 
ence of redness are always present to a greater or less degree at the early period 
of inflammation ; and whether the redness be always present or only slightly 
perceptible, the same impairment of function among the minute elements of 



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PATHOLOGY OF THE INFLAMMATORY PROCESS. 71 

the tissue, and increased adhesiveness of the blood-discs, not only to each other, 
but to the tissue of the capillaries, take part in the development of the inflam- 
matory process. 

The enlargement of the bloodvessels varies. It may be hardly perceptible, 
or it may increase their diameter to two or three times their natural size. 
John Hunter established this stage of the inflammatory process in the ear of 
a rabbit, by thawing it after it had been frozen : the rabbit was killed during 
the process, and the head being injected, the two eai-s were removed and dried. 
Woodcuts representing the comparative conditions of the two ears may be 
seen in the firat volume of Paget's Surgical Pathology, p. 295, or at p. 221 of 
the edition edited by Professor Turner. The bloodvessels of the inflamed ear 
became greatly larger than those of the healthy one, and it was found that 
arteries before invisible, in the healthy state of the rabbit's ear, were brought 
clearly into view during the stage of the inflammatory process. 

The redness of an inflamed part is of various intensity and shade, according 
to the degree of the inflammation, its stage, and the structure (especially as 
to bloodvessels) of the part aflected. Its shades pass from a light rose-color 
to a deep crimson, or even purple. It assumes the form of points where con- 
geries of minute bloodvessels are concerned ; or streaks, as where the vessels 
of fibrous structures are inflamed, as in tendon ; or a series of minute and fine 
ramifications, as in synovial structures ; and generally, it may be stated that 
the form of the redness derives its character from the normal arrangement of 
the capillaries of the part. The redness is most intense towards the centre of 
diseased action, gradually softening down towards the circumference, where 
the conditions of health exist. This gradual shading ofi" serves to distinguish 
the redness of inflammation from the redness of extravasation. The margin 
of an extravasation is defined, its redness cannot be removed by pressure ; 
while the disappearance of inflammatory redness under pressure is, to a certain 
extent, a measure of the activity of the circulation in the part. 'The brighter 
hues generally attend ordinary active inflammation ; — the darker hues of in- 
flammatory action are generally associated with some specific cause of disease, 
a feeble action of the parts, or a tendency to gangrene. The increased depth 
of color is mainly due, in the first instance, to the congestion and stagnation 
of blood in the existing vessels, and not in any measure to the formation of 
new ones. The redness, however, always appears more than proportionate to 
the enlargement of the bloodvessels ; and we find that the red corpuscles are 
intensely adherent in the enlarged capillaries. 

The dilated vessels of an inflamed part appear crammed with red corpuscles, 
which lie or move as if no fluid intervened between them, or as if they were 
imbedded in a hyaline substance due to the solidification of the fibrin of the 
liquor sanguinis. An increase of redness is sometimes seen to depend upon 
extravasation of blood, the distended and softened capillaries breaking from 
the pressure of the blood, or the effusion of the coloring matter of the blood- 
corpuscles, as well into the spaces between the blood-corpuscles as into the 
adjacent tissue through the walls of the bloodvessels. Lastly, the redness is 
sometimes intensified (as Hunter first suggested, and microscopic examina- 
tion subsequently proved) by the passage of the blood, unchanged, from the 
arteries into the veins. No new formation of bloodvessels is necessarily con- 
cerned in the redness of inflamed parts ; but as inflammation continues and 
advances, new bloodvessels gradually develop themselves, and which, like the 
old ones, become filled with blood. When infiammation has subsided, these 
new vessels pass into any new growth of tissue which may have arisen, as if 
for its nutrition, development, and continued growth, or to effect its subsequent 
removal, degeneration, decay, or absorption. 

Peculiar changes of shape are associated with enlargement pf the blood- 
vessels, consisting chiefly of tortuosity of distribution and aneurismal or vari- 
cose dilatation. The aneurismal or varicose state is seen to take place most 



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72 TOPICS RELATIVE TO PATHOLOSY. 

frequently in the soft textures, as in the brain, where it is a frequent condition 
of the inflammatory red softening (Kollikee and Hasse) ; and in subcuta- 
neous tissue, the points of what appears to be extravasated blood are aneur- 
ismal dilatations of capillary vessels filled with the red corpuscles (Lebeet), 
as shown in the woodcut. 

Fig. 1. 




Dilated bloodvessels in inflaraniation, after Paget. 

These varied conditions of the bloodvessels affect the motion of the fluid 
in the part ; and consequently the supply of blood for the purposes of nutri- 
tion. Generally it may be stated that there is stagnation of the blood in the 
focus or centre of severe inflammation. This stagnation is surrounded by a 
state of fiilness of vessels and slow movement of the blood, while farther around, 
and more distant still, there is fulness of the vessels, with a rapid movement of 
the blood. Prom the discrejsancy existing among observers regarding the 
statement as to whether the motion of the blood is slower or quicker when 
the vessels are contracted or dilated, there is evidence that the contraction 
alone of a vessel, or its dilatation alone, is not always sufficient to cause the 
current of blood to be either slow or quick. Other conditions are at work 
which contribute in no small degree to accelerate or to slow the rate of move- 
ment in the vessels. Besides the force of the heart's action, there is a mutual 
relation which subsists between (a) the blood, (h) the bloodvessels, and (c) 
surrounding tissue, which materially influences the active motion of the blood. 
In the healthy body this mutual functional relation between the minute ele- 
ments of tissue and the blood is necessary to maintain it in a state flt for 
transmission through the vessels. The mere contraction of the arteries leading 
to a part does not tend to stagnation of the blood in the capillaries of the 
inflamed part ; on the contrary, the movement onwards of the blood in the 
vessels is influenced or modified by the vital functional processes going on 
between the capillary vessels and the surrounding elements of tissue, and 
which has been variously named the "capillary force," the "vital force," the 
"nutritive force;" it is also mainly influenced by the action of the heart itself, 
and by the physical condition of the vascular tubes through which it has to 
pass. ^ Accordingly at first, with contraction of vessels, the current has been 
described as being quickened. It also sometimes slackens, or even retrogrades 
for a time, and not unfrequently oscillatory movements may be noticed. But 
when dilatation is complete, the blood flows with rapidity, and a greater 
quantity passes during a given time than in the unexcited state of the parts. 
This is known as the state of " determination of blood to a part," or " active 



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PASSAGE OF BLOOD-COKPUSCLBS THROUGH VESSELS. 73 

congestion." The natural function of the part thus becomes simply exalted ; 
and it may be said that a step beyond this will pass the confines of that 
neutral ground which exists between health and disease. With an increased 
circulation, and such " determination of blood to a part," functional activity 
is not only maintained, but is promoted and increased ; and unusual transu- 
dation of the nutrient material may take place, chiefly of the serum of the 
blood. Hence the oedema which surrounds an inflamed part. After a time 
the motion of the blood becomes slower, while the volume propelled is in- 
creased, and the retardation gradually increases till the blood-corpuscles are 
no longer propelled, floating in their liquor sanguinis; but, accumulating in 
masses, they advance by a jerking intermittent motion, till at last complete 
stagnation takes place. The blood-corpuscles now detained exhibit a marked 
tendency to adhere alike to the walls of the vessels and to each other ; thus 
accumulating together and sticking in the capillaries, while the liquor san- 
guinis flows onwards. To this condition the term "stasis" has been applied. 
In the immediate neighborhood, and surrounding the part which is in the 
condition of stasis, the circulation of the blood goes on with increased rapidity : 
it may even pulsate in the arteries and oscillate in the veins, while it moves 
with a uniform but rapid flow through highly distended but less turgid vessels^ 
When these conditions exist simultaneously, and the true morbid process is 
completely established, the capillary vessels may burst, causing hemorrhage 
or extravasation into the surrounding tissue, or the serum and liquor sanguinis- 
may transude through their walls, without rupture, into the surrounding 
texture. But not only does the serum and liquor sanguinis make way without 
rupture through the capillary walls (whose texture is peculiarly permeable),, 
but the observations of Professor Strieker conclusively show that capillary 
canals undergo changes of calibre, while the red blood-corpuscles sink. intO) 
and through the substance of the unbroken capillary wall. Sometimes these 
blood-corpuscles will remain with half their volume within and half their 
volume without the bloodvessels, having an hour-glass constricted shape,, the 
wall of the bloodvessel in this case having an amo3ba-like capacity for being; 
protruded or impressed upon, permitting the corpuscles to permeate or pass,, 
as the swimmer passes through fluid without leaving a trace of his wa,y. Dr., 
William Addison, in 1842, also published, in Transactions of Provincial Medical 
Association and in subsequent writings, that white corpuscles not only accu- 
mulate in the vessels of inflamed parts, and adhere to their walls, but that; 
they seem to become incorporated with the substance of the vessel,, and to- 
pass through it (without permanent solution of continuity), into the sur- 
rounding tissue, where they constitute the corpuscles of inflammatory lymph,, 
pus, or mucus. The red corpuscles act similarly. Dr. Augustus Waller re- 
corded similar observations in 1846 {Philosophical Magazi7ie,Yo\...^'sx£).. In. 
1868, Cohnheim, of Berlin, also came to the conclusion, from experiment and-, 
actual observation, that not only the white but the red corpuscles pass through 
the walls of capillaries and veins of irritated and inflamed parts; and. that 
they may even migrate to some distance from- the vessel through which they 
have permeated — their movements being like those of an amojba ; that is,, 
having a power of spontaneous movement by various changes of form,, as by 
sending out processes, blunt or thread-like, to be again withdrawn,, and the 
spheroidal form resumed. Thus, by repetitions of these changes of form, the 
blood-corpuscles change from place to place. He believes the white corpuscles 
become pus-cells. 

Two novel features have now therefore been slowly demonstrated smce- 
Addison's observations on the phenomena of inflammation, namely — first,. 
the yielding permeability of the soft, nucleated protoplasm which forms the 
walls of the living capillaries ; and, second, the spontaneous amoeboid move- 
ments possessed by the corpuscles of the blood. Any visible pores, or stomata,, 
are not found to exist in the walls of the capillaries. Recklinghausen, in 

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74 TOPICS EELATIVB TO PATHOLOGY. 

Berlin, and Professor Bastian, of the London University, Lave each con- 
firmed these observations. 

" The determination of blood to a part," characterized by dilatation of the 
arteries with increased flow of blood through the capillaries, must be distin- 
guished from the "passive congestion," characterized by the accumulation and 
stagnation of red and white corpuscles in the vessels, tending to be abnormally 
adherent to each other and to the vessels, associated with low vital activity. 
Both of these phenomena, namely, " determination " and " congestion,"_ may 
result from irritation. The dilatation of the arteries seems to be immediately 
developed through the medium of the nervous system, while the accumula- 
tion of the blood-discs and stagnation of the blood is the immediate and 
direct result of impaired or suspended function of the minute tissue-elements 
contiguous to the capillary vessels. 

The " determination of blood " and dilatation of the arteries lead to no 
change in the quality of the blood itself; on the other hand, accumulation 
and stagnation of blood, in the congestion of an inflamed part, are associated 
with increased adhesiveness of the red and white discs. Mere determination 
of blood becomes obliterated after death by the post-mortem contraction of the 
arteries, whereas passive congestion is persistent. It is an evidence of organic 
lesion declaring itself as distinctly in the dead as in the living ; and thus the 
most important, if not the only sign, of the early stage of inflammation having 
occurred during life, is recognizable, on dissection, by the intense redness due 
to the accumulation of red discs adherent to each other in the minutest rami- 
fications of the vessels, and not due to distension of the vessels merely. 

Such is a statement of the facts ascertained regarding the early phenomena 
of the inflammatory process ; and they are of such a kind that, with the 
facilities of study which ought now to be within the reach of every student 
of medicine, he ought to make such experiments as have been already noticed, 
or see them made by others, and thus really appreciate the steps of that mor- 
bid process which he requires to treat so extensively in practice, and of which 
he can form but a faint conception from the most lucid description. 

II. The constitution of the blood is altered as regards its adaptability to 
nourish the part. 

The nature of this alteration cannot be chemically expressed ; but micro- 
scopical observation has established a fundamental fact, namely, that the tis- 
sues through which the blood flows have suQh special relations to the living 
fluid that, in the healthy state, the functional activity of the minute tissue- 
elements maintains the blood in a state fit for transmission through the blood- 
vessels ; and the first change observed in the blood, subsequent to impaired 
function of tissue-elements, is an increase of adhesiveness of the red as well 
,asof the white corpuscles ; but the white corpuscles are now known to be sus- 
ceptible of much greater adhesiveness than the red ; so that slight irritation, 
leading to impairment of function, causes stagnation of the white sooner than 
of the red discs. The blood is not thus altered in the first instance through- 
out its whole mass ; but the change is a local one, confined to the seat of the 
inflammatory process. At one time it was believed that the blood was altered 
in its constitution chiefly by an increase of the fibrin and the white cor- 
puscles ;* but it is now found that the white or rudimental corpuscles of the 
blood cannot be separated from the fibrin by any known process ; conse- 
■quently the relative amount of fibrin cannot be correctly stated in relation 

* Andral and Gavarret showed that the proportion of fibrin in tlie Wood was aug- 
imeiiited in inflammations, wlien sufficiently severe or extensive to afli'ect the system. 
In health the average proportion is three parts in 1000, and in cases of severe inflam- 
■matio'ns it has been found to rise as high as eight, nine, or ten parts in 1000. This 
increase commences as soon as the inflammation is established, and ceases when the 
process begins to decline. 



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APPBARANCES OF THE BLOOD IN INFLAMMATION. 75 

to the blood. And, as in many inflammations these corpuscles are increased, 
as well as ia many conditions, such as pregnancy, in which no inflammatory 
process exists, the blood is similarly altered, it is not known how much of 
change is due to fibrin or how much to the white corpuscles. The generation 
and accumulation of large numbers of white corpuscles in the vessels of an 
inflamed part is not now received as a fact. The phenomenon may be true 
as regards some frogs, but not as regards warm-blooded animals ; and it is 
consistent with the experience of three most eminent pathologists who have 
experimentally examined this subject — namely, Mr. Wharton Jones, Dr. 
Hughes Bennett, and Mr. Paget — that an especial 'abundance of white cor- 
puscles in the vessels of an inflamed part is neither a constant nor even a fre- 
quent occurrence. Dr. Hughes Bennett's researches relative to leucocythamia 
have shown that even the most extreme abundance of white corpuscles in the 
blood has no tendency either to produce or to aggravate inflammations. 

A remarkable phenomenon presented by the red blood-corpuscles in inflam- 
mation was first observed in 1827 by Mr. Lister, Sen., and by Dr. Hodgkin, 
and afterwards accurately described by Mr. Wharton Jones. 

They observed that when healthy blood is received on a glass plate, or the 
clean surface of a polished lancet, and immediately examined, the corpuscles 
lie difiused in the liquor sanguinis, but in about half a minute they run 
together into piles or rouleaux, which arrange themselves in small-meshed 
networks. But if a drop of blood from a patient with acute rheumatism, or 
with an inflammation, be similarly examined, piles of red corpuscles instantly 
form, and are clustered into masses, leaving a network with wide interspaces. 

This appearance of itself, however, is not a sure sign of inflammation. It 
may be observed in the blood of the chlorotic female as well as in the pregnant 
one ; in those also in whom a plethoric condition as regards the blood exists ; 
in persons in health whose circulation has been much accelerated, as by vio- 
lent exercise ; and it appears to be the natural state of the blood of horses. 
It is a phenomenon resulting from an increased tendency to aggregation of the 
blood-corpuscles, and gives a granular appearance to a thin layer of blood 
when viewed with the naked eye. When blood is drawn ofi' in quantity, the 
phenomenon is associated with the formation of what is termed the "bufiy 
coat," as the clustered blood-corpuscles, rapidly sinking, subside to some dis- 
tance below the surface before the fibrin and the white corpuscles begin to 
coagulate. The connection is now well established between the yield of fibrin, 
as expressed by a bufij^ coat, and the existence of acute infiammation. 

It has been found greatly increased in rheumatic fever, pneumonia, pleurisy, 
bronchitis, peritonitis, quinsy, erysipelas ; and the buffy coat over the contents 
of the bleeding-basin was wont to be an ordinary element in diagnosis, and a 
justiflcation for the bloodletting (Simon). 

However indefinite and uncertain the changes may be, as observed upon a 
small portion of the blood, it cannot be doubted that the blood stagnant or 
retarded in an inflamed part undergoes important alterations ; and by a con- 
stant succession of such changes the whole fluid may come at length to be 
materially altered, as indicated by the general effects and constitutional dis- 
turbance, extending throughout the nervous and the vascular system, and 
which may ensue in the train of an inflammation of purely local origin. It 
is probable that local changes ensue in the blood similar to those we shall 
have to notice as taking place in the products of growth in and amongst the 
elements of tissue during the inflammatory process. There is no doubt, as 
Wharton Jones has shown, that fibrinous coagula occasionally form, and even 
degenerate, within the bloodvessels. When the stagnation of the blood is not 
constant, these fibrinous coagula are carried away into the general circulation, 
giving rise to the phenomena of embolism (to be afterwards described) in the 
capillary vessels of some of the more solid viscera, such as the brain, lungs, 
liver spleen, or kidneys. By the degeneration of such coagula the whole 



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76 TOPICS KELATIVE TO PATHOLOGY. 

mass of blood may be infected, and constitutional disturbance excited, pro- 
ducing sometimes various and widespreading suppuration, — as when purulent 
infection is consequent on local injury, or when a blood-clot passes upwards, 
and, becoming lodged in the cerebral vessels, induces the state known as soft- 
ening of the brain. 

There are many points or questions deserving of attention regarding the 
theory of the inflammatory process ; but it is also obvious that, in a text-book 
such as this, any mere analysis of speculative doctrines ought not to take up 
much space. The following statement will therefore merely embrace as much 
as possible of those topics of special interest which a more extended and accu- 
rate physiological knowledge of the process of inflammation has shown to be 
the proper objects of more extended inquiry. 

In the first place, as to the primary seat of the inflammatory process, there 
can be little doubt, from the phenomena already described, as well as 
from the results of dissection, which show the progress and effects of the 
process, and from the experimental researches of Hunter, Thomson, Wilson 
Philips, Hughes Bennett, Wharton Jones, John Simon, Paget, Lister, and 
other observers, that the vital morbid process known as "inflammation" is 
connected with the minute capillaries, and the most minute elements of tissues 
which they nourish. Questions relative to the theory of the process are there- 
fore found to be intimately connected with the histological and physiological 
relations of these parts ; and especially with more recent knowledge as to the 
structure of the capillaries, and the movements through their walls of cor- 
puscles of the blood. 

During the earliest period of the process — the period of increment, or of 
incubation, as it has been termed — it appears to be the inherent properties of 
the minute component elements of tissues which first undergo a change, and, 
combined with the reflex actions of the nervous system, seem to maintain, to 
promote, or to increase the activity of the subsequent stages. 

The simplest effects upon the minute elements of tissue, and upon the blood- 
vessels, are seen to follow the application of the mildest or slightest physical . 
or chemical agents, but which, operating powerfully, are also capable of extin- 
guishing _ altogether the life of these elements of tissue. When the action 
induced is mild and gentle, the tissues become incapable of performing their 
wonted functions ; and, provided the mechanical or chemical agency has not 
been too severe, the impairment of function may subside, and the tissues will 
return to their normal state of functional activity. This is "resolution" of 
the inflammation. 

Such irritant causes acting either immediately from without, or through the 
blood, or through the instrumentality of the nerves, each component texture 
of the part becomes affected as soon as it is brought in contact with the irri- 
tant. A gradual contraction of the arteries takes place — the contraction 
following at some interval after the application of the stimulus — is slowly 
accomplished, and persists for a variable length of time. Relaxation then no 
less gradually ensues, when the capillaries open up and slowly dilate, till 
they acquire a size larger than they had previous to the application of the 
stimulus. 

The minute arteries have been shown by the histologist to possess in abund- 
ance, the structural elements of the non-striated contractile tissue ; and in this 
respect they closely resemble the constitution of the muscular fibre of the 
intestine. Accordingly, the contractions they undergo have been considered 
as analogous to spasms (as Cullen first suggested) ; while the succeedmg dila- 
tation may be of the nature of relaxation, and ultimately of paralysis!' This 
paralyzed state is shown from the fact that the same vessels now dilated will 
not contract upon a reapplication of the same stimulus which before made 
them contract. If the stimulus is made with a needle upon the vessels in the 
transparent parts of an animal, the needle may be repeatedly drawn over 

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THEORIES OF INFLAMMATION. 77 

such dilated vessels and no contraction will follow ; but with a stronger stimu- 
lus, such as that of heat, they may be made to contract again, and even close ; 
and this state of contraction may persist for a whole day, before the vessels 
again open up and permit the blood to flow (Paget). 

On the other hand, the true capillaries seem totally destitute of any special 
structure known to be contractile. They merely consist of a delicate, yield- 
ing, homogeneous, contractile protoplasm, beset with occasional nuclei, and, 
like protoplasm, having the power of developing processes or outgrowths. A 
film of collodion is not more homogeneous nor more continuous than the mem- 
brane of a capillary ( Viechow). Whereas the minute arteries (some of them 
less even in calibre than capillaries) possess distinct coats, one of them con- 
sisting of a single layer of muscular (or contractile) fibre-cells, wound spirally 
round the internal membrane of the bloodvessel, so as to encircle it from one 
and a half to two and a half times. The arteries, to their smallest branches, 
are sometimes contracted to absolute closure, and at other times are widely 
dilated ; whereas the capillaries are never entirely closed, nor do they present 
any variations in diameter which are not due to the elasticity or yielding per- 
meability of their parietes (Lister, 1. c). 

The most interesting point in the whole process is perhaps that which em- 
braces an inquiry into the cause of the " stasis," or stoppage of the blood, the 
exudation of the liquor sanguinis, and the permeation of blood-corpuscles 
through the yielding walls of the capillaries. This is a point which I think 
the observations of Professor Lister have so very beautifully illustrated ; but 
the explanations of other eminent pathologists and experimentalists, if not 
universally satisfactory, serve to present the subject in a variety of aspects to 
the mind, which cannot fail to be both interesting and practically instructive. 
Henle, Simon, Bennett, Williams, Addison, Rokitansky, Paget, Strieker, 
Cohnheim, and Bastian, have all helped to elucidate the process by the fol- 
lowing theories : 

The theory of Henle, or, as it is sometimes called, the " neuro-pathological 
theory," assumes that the stimulus, acting on the sensory nerves of the part, 
excites in them a state which, being communicated to the spinal nervous 
centre, is reflected on. the vascular nerves, occasions their paralysis, and there- 
with paralysis also of the contractile coat of the bloodvessels. Various modi- 
fications have been made upon this theory ; but, as the phenomena have been 
seen to take place in the case of absence of a spinal cord, and in di-\^ision of 
the roots of the nerves, and in section of the lumbar and sciatic nerves, such 
facts are subversive of the hypothesis. Henle considers the stasis as a, neces- 
sary physical consequence of this dilatation of the bloodvessels, and this stasis, 
together with the relaxed and dilated state of the vessels, favors the_ exudation 
of serum, the consequence of which is, that the plasma of the blood in the part 
becomes inspissated by a preponderance of albuminoid matter over the salts. 
This inspissation of the plasma determines endosmotic changes in the red cor- 
puscles, in consequence of which they are disposed to aggregate. 

Simon propounds the view that the phenomena are due, not to a reflex 
action, but to a direct change effected by the living molecular structure of 
the part on the blood which traverses it, or on the vessels which convey that 
blood. 

Bennett ascribes the change as due to a vital force actively operating 
through the tissues which lie outside the vessels, and which is the only active 
agency causing the approach of the colored particles to the capillary walls of 
the bloodvessels, and the passage through them of exudation. _ 

Paget and Lister suppose a mutual relation to exist between the blood, its 
vessels, and the parts around, which, being natural, permits the normal 
transit of the blood, but being disturbed, increases the hindrances to its 



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78 TOPICS RELATIVE TO PATHOLOGY. 

Dr. C. J. B. Williams considers that an essential part of inflammation is 
the production of numerous white globules in the inflamed vessels, and that 
the obstruction of these vessels is mainly due to. the adhesive properties of 
these globules. 

Eokitansky is of opinion that the condition of stasis proceeds, — 1st. From 
the sticking together of the blood-corpuscles, the heaping up and wedging of 
them in the capillaries, while the. plasma in part flows off towards the veins; 
2d. From the inspissation of the plasma, occasioned by the exudation of serum 
through the dilated and attenuated walls of tlie vessels, and its saturation 
with fibrin and albumen; 3d. From the heaping up of the colorless cor- 
puscles, i. e., the nucleus and cell-formations, together with blood-globules'; 
from their sticking together, and from the delicate hyaline, fibrinous coagula 
which develop themselves among them. Eokitansky considers this to be the 
most important moment in the inflammatory process, since on the one hand 
it very specially throws light upon the phenomena of stasis, and on the other 
hand it comprehends the plastic processes which take place in the heaped-up 
and stagnant blood. It separates in this way the process of inflammation 
from a merely simple one of exudation. The elementary formations above- 
mentioned are not merely swept together towards the place of stasis, but they 
originate as new formations in the stagnant blood, which generally presents 
remarkable alterations. 

Wharton Jones describes the progress of stasis as consisting, — 1st. Of the 
adhesion of collapsed and dark-red blood-corpuscles to the walls of the ves- 
sels ; and, 2d. The adhesion of other blood-cells to these. The first adhesion 
of the blood-cells usually takes place at a bifurcation, and the stagnation of 
blood is seen to begin in those capillaries which are least in the direct course 
from the artery to the vein, depending in a great measure upon the inspissa- 
tion of the plasma, or its increased quantity of fibrin and albumen. - 

Whatever explanation may be given or accepted as to how the phenomena 
of inflammation in a part are brought about, our views regarding the essential 
nature of the process have been hitherto modified according as this complex 
morbid state has been studied by its effects as seen on the dead rather than 
on the living body. 

While Dr. Bennett regards an exudation from the bloodvessels as the neces- 
sary constituent of inflammation, Alison and Virchow, on the other hand, rec- 
ognize the morphological changes of the living tissues, such as have been 
described in inflammation, as betraying merely a tendency in a part to such a 
local change as exudation amongst its structure. That heal tendency may be 
so slight that hardly any difference can be appreciated between the healthy 
changes attendant on normal nutrition, and those changes between the blood 
and the minute tissues which are of such a kind that a morbid change (inflam- 
mation) is established in the elementary components of the tissues themselves, 
without any appreciable exudation having taken place either amongst the 
interstices or upon the free surfaces of membranes. To such a condition Vir- 
chow gives the name of parenchymatous inflammation, meaning thereby that it 
is a process established locally between the capillaries, the blood, and the 
component elements of tissue, and expressed by a tendency merely to the 
effusion from the bloodvessels of such plastic material as may eventually take 
place. 

Inflammation may thus exist as a local morbid process, characterized by an 
abnormal condition of the nutritive changes between the capillaries, the 
blood, and the component elements of a texture, without any appreciable ex- 
udation. Such an abnormal condition will, under proper regimen and proper 
remedies, in a case of simple inflammation, seen from the first, completely 
subside, no interstitial exudation ever taking place. 

Examples of this simple form of inflammation have been fiilly illustrated 



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PARENCHYMATOUS INFLAMMATION. 79 

by Goodsir and Redfern in this -country, by their demonstrations of what 
takes place within the large cells of cartilage. The 
cells become larger, the number of nuclei increases, and ^™- ^■ 

some; or all of them, may undergo fatty metamorphosis 
under the influence of this, the simplest form of inflam- 
mation ; and which is only manifested by this abnormal 
nutritive process between the blood and the cells. 
These changes within the cell-elements of tissue are 
described by Virchow as a " cloudy swelling " (triXbe 
Soliwdlung, Fig. 2) of the parts, and are seen, for exam- 
ple, in the cells of the uriniferous tubes, and those of 
the mucous membrane in the state of catarrh. In this 
abnormal nutritive process, however, there is a constant 

tendency to the interstitial exudation of a hyaline ma- 

terial, which may become fibrQus or filamentous, and looothof an'inchxssodiam. 
ultimately soft and gelatinous. Virchow, Weber of convoluted urinary tutiuie 
Bonn, and His, ha;ve demonstrated similar changes in f™™.«'e cortex of a kidney 

,',,„,,' ^ m Bnglit's disease (alter ViR- 

tne cells Ot the cornea. chow), (a.) Tolerably nor- 

Thus the minute and penetrating observations of ^ll^'^'S^g' ;HTct^- 
Virchow have given a more comprehensive meaning to mencing fatty degeneration 
the process of exudation than it has hitherto, in this '"' '^'° "^^'^ ^°"' 
country, been understood to signify ; and such alterations as he and others 
have described in the elements of the tissues of an inflamed part have been 
in a great measure overlooked, except by Dr. Alison and Mr. Simon. The 
latter especially states that the irritation of the inflammatory process is inde- 
pendent of the nervous influence, hut is a direct change operated by the living 
molecular structure of the part on the blood which traverses it, or on the vessels 
which convey that blood. Dr. Alison, also, long ago recognized the tendency to 
interstitial exudation as attending such vital changes in the constituent ele- 
ments of a part, and which entitled it to be considered inflamed. The accurate 
observations of Virchow, Goodsir, and Eedfern have shown that such primi- 
tive changes do take place before those more palpable phenomena occur which 
constitute the excessive exudation as described by Bennett, namely, the exu- 
dation of decolorized lymph into the interstices between the constituent ele- 
ments of a texture. Both sets of phenomena alike show that inflavimation 
is only one of the various shades of deviation from the normal process of nutri- 
tion, — a diseased action tending to a local lesion (British and Foreign Medico- 
Chirurgical Review, January, 1854). That the irritation of inflammation is 
in some measure independent of the nerves, the following interesting experi- 
ment, related and performed by Mr. Simon, may be quoted in proof: 

" A patient had complete anaesthesia of the fifth nerve, dependent (as a post- 
mortem examination subsequently showed) on its organic disease; the con- 
junctiva, as well as the integument of the face, was utterly insensible ;_ not 
only was the function of the nerve destroyed, but those reflective nutritive 
changes, of which I have already spoken, had taken place, and had exhausted 
themselves ; showing that the nerve was spoiled for participation in the acts 
of nutrition (whatever they may be) no less than for its more obvious uses as 
a medium of conscious sensation ; the cornea had undergone ulceration, and 
had healed again. The following experiment was carefully made : The lids 
being held open, a single granule of cayenne pepper was laid upon the insen- 
sible conjunctiva ; in a few moments if had become the centre of a very dis- 
tinct circle of increased vascularity, the redness of which slowly became more 
and more distinct as long as the stimulus was suflfered to remain, so that, on 
its removal, there was a very evident circumscribed erythema on the surface 
of the membrane. I consider myself justified in believing that this change 
occurred without any intermediate nervous excitement ; not only because the 



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80 TOPICS RELATIVE TO PATHOLOGY. 

history of the case would lead me to consider the fifth as annihilated ; not 
only because the experiment was-totally unattended with sensation ; but like- 
wise because there was the very remarkable absence of that sympathetic phe- 
nomenon which the faintest remnant of nervous excitability would have 
produced— namely, there was not the slightest trace of lachrymation " (Lectures 
on General Pathology, p. 76). 

Further evidence might be submitted from the papers of Mr. Joseph Lister 
to the Royal Society, already referred to. 

Such being the essential nature of inflammation, it is easy to understand 
how reasonable is that doctrine which teaches " that the process of inflamma- 
tion is susceptible, at all times aud in all countries, of very great variety as 
to extent or intensity, and especially as to the constitutional afiection associa- 
ted with it or consequent upon it." 

Products, Effects, or Events of Inflammation. — Care must be taken not to 
put the products of inflammation in place of the symptoms of inflammation. 
When the local impairment of function of the minute elements of tissue in 
process of inflammation is confined to a small space, or is carried on upon a 
minute scale, or rapidly abates, the inflammation is said to terminate^ by resolu- 
tion as a general principle ; that is, the abnormal action ceases, interstitial 
exudation does not take place, the tendency to further impairment of func- 
tion is subdued and passes off, and the part is left apparently as it was before. 
If, however, interstitial exudation has taken place, and resolution is to be 
effected, the return of the part to health may be followed, for some time, by 
some impairment of its structure and function. 

After the process lias thus gone a certain length, an increased local growth of 
cells, and their liquefaction or reduction to a state capable of absorption (what 
Dr. Addison calls cell-therapeutics), are essential to the restoration of the part. 
Before the process has attained such a length, however, resolution may be 
simply effected by a gradual return of all the parts to a natural state : a mere 
retracing of the steps by which the natural actions had been departed from 
sufficiently describes the process (Paget). 

The process of resolution has been closely watched by Mr. Paget. He has 
seen, in those cases where impairment of function and actual lesion had taken 
place, that fragments of fibrin, washed from the blood in the vessels of the 
injured parts, were borne along and floated into distant vessels. The observa- 
tions of Dr. Kirkes, also, leave no doubt that similar changes may occur in 
warm-blooded animals, and may be the source of great evils ; may be, indeed, 
productive of some of those constitutional effects yet to be noticed, by carrying 
the materials of diseased or degenerate blood from a diseased organ to one 
that was previously healthy. When the disappearance of the inflammation 
is unusually sudden and rapid, the event is technically called " delitescence ;" 
and if at the same time the symptoms of inflammation appear at another part 
not anatomically coianected with the part first diseased, the event is called a 
" metastasis." 

When the process does not confine itself to the simple expression of altered 
nutritive changes between the constituent tissues of a part and the blood ; but 
when the tendency to exudation amongst the interstices of texture continues, 
.and does not subside, as already explained,-^namely, by resolution, — ^then it 
is that (1) such a material is separated from the blood as will become a me- 
dium or nidus-suhstatice, in which many changes connected with the growth of 
new particles, granules, or cell-forms will take place, and the phenomena of 
-which have been so well described by Bennett, Gluge, Paget, Virchow, Beale, 
.and John Simon ; and (2) coincident with this exudation, and the changes 
which it undergoes, the tissue of the part itself sustains serious alterations. 
For in all such inflammations, especially of the more vascular parts, when 
-.there is increased exudation from the bloodvessels, there is a great deteriora- 



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SEROUS, FIBRIN, AND BLOOD EFFUSIONS. 81 

tion of the surrounding elements of tissue. The texture is rendered soft and 
easily torn, and by such changes of cohesion the elasticity of parts (a circum- 
stance often of very primary importance) becomes greatly altered and im- 
paired. 

These changes, therefore, Mr. Paget happily describes as consisting of,— 
(1.) Productive eifects — that is, effects resulting from the growth of new parti- 
cles, granules, or cell-forms, from pre-existing germinal elements of tissue, and 
which are susceptible of further development, and also of degeneration; (2.) 
Destructive effects, such as softening, degeneration, absorption, ulceration, and 
death of tissue. 

Productive Effects of Inflammation — ^Inflammatory Eifusions or Exuda- 
tions — These consist of, — 1. Serum ; 2. Blood ; 3. Fibrin ; and, 4. Mucin. 
These last two are the only true inflammatory exudations. 

1. Serous Effusions. — The effusion of pure serum is said to be very rare. 
In Inflammation of a serous membrane, as the pleura, the fluid efiused is not 
only greater in quantity than natural, but is also greatly altered in quality. 
In health, the serous secretions are little more than pure aqueous vapor, with 
a trifling addition of saline matters ; but when they occur in an inflamed part, 
they contain a considerable quantity of albumen, sometimes a portion of fibrin, 
and at other times the secretion appears to be the pure liquor sanguinis which 
is effused, entirely unchanged in its physical properties. The quantity efiused 
varies, according to the part affected, from perhaps a portion of an ounce to a 
few pints, or even more than a gallon. 

This product of inflammation, but mixed with fibrin, may be seen in the 
fluid contained in blisters raised by counter-irritants in a healthy person ; 
also in the fluid oi peritonitis ; oi pleurisy and oi pericarditis : such also is the 
fluid that fills the early vesicles of herpes and eczema, and other cutaneous 
eruptions. It is also seen in the fluid which surrounds an acute, deep inflam- 
mation beneath the skin. The fluid of a common hydrocele is another exam- 
ple of serous effusion. The phenomena associated with the production of such 
a secretion may be often seen surrounding a phlegmon or boil of large size. 
While the centre or core of the boil is hard, it is surrounded by textures into 
which the effusion that has taken place is serous. Such serum is seen to a 
great extent in pelvic cellulitis in its fii-st stage. A very demonstrative and 
interesting example of this is given by Professor Simpson, of Edinburgh, in 
the Medical Times and Gazette for 1859, p. 27, July 9. In such cases the fluid 
fills the areolar tissue which immediately surrounds the inflamed parts ; and 
when the finger is pressed firmly on the part, the fluid is displaced into the 
adjoining areolar spaces, which yield to receive it. When the finger is with- 
drawn, the fluid does not immediately return, but an impression is left in the 
shape of a pit. The part which is the seat of serous efiusion is then said, to 
pit on pressure, or to be cedematous. • , • ^ 

The fibrin of infiammatory serous effusions remains m solution for weeks 
or months within the body, during life, but will coagulate readily when withr- 
drawn. ■ This delay of the fluid to coagulate within the body is a propitious 
event. So long as it is liquid, absorption may still ensue without its undergo- 
ing any ulterior change when the inflammation subsides. This subsidence of 
the inflammation, however, is necessary, for it is known, that so long as inflam- 
mation continues, there is impairment of function, and absorption does not 

'^One constant characteristic oiihQ productive efiects of infiammation, is, that 
growing material is always developed from the pre-existing germinal elements 
of the tissue involved; and the efiusion that results from mere mechanical 
obstruction to the flow of blood is very difierent froni the fibrinous effusion of 
an inflammation. In the former case the fluid effused from the blood is merely 
the serous part, as the fluids of anasarca and ascites, and will not coagulate.. 



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82 TOPICS RELATIVE TO PATHOLOGY. 

Such fluids, as a rule, neither present fibrin, nor are any granules, particles, 
or cell-forms developed in them from the elements of surrounding tissue. 

Fibrin can only be made to exude upon any surface or part in a state of 
irritation or inflammation. Such a local change is sufficient to cause the 
exudation of fibrin, independently of obstruction to the circulation ; and the 
cause of the greatest diflferences in the nature of exudations is to be found in 
the special constitution of the irritated parts (Viechow). In some efiusions 
there is a great yield of fibrin, e. g., the exudation of diphtheria, so also in 
the effusions of ortitis and of muscular rheumatism. 

It has been clearly shown (Simon, Lehmann, Beale) that there are two 
essential characteristics of inflammatory eflTusion: (1.) It tends to contain 
certain ingredients in larger proportion than that in which they exist in the 
blood — excess of chloride of sodium and of phosphates and albumen; (2.) 
Organic forms find in it a suitable place for growth. 

The site of effusion resulting from inflammation is important, as sometimes 
constituting the chief element of danger — a danger sometimes immediate, 
from the mechanism of the parts affected. A large quantity of fluid is often 
poured out in a very short time. The cavity of the pleura may fill in a few 
hours, and the lung may be compressed by it to a half or third of its bulk; 
and if both pleural cavities become thus affected, constituting double pleurisy, 
the patient must die from suflTocation, if not at once relieved by allowing free 
vent to the fluid. This operation is called tapping the chest, or, technically, 
" paracenteds thoracis." Serous effusion into the areolar submucous tissue of 
the glottis may also produce almost immediate death from suffocation, unless 
the cavity of the larynx is immediately opened to admit the air to the lungs 
(Watson). 

2. Blood Effusions, or Extravasatio7is, chiefly occur from rupture of the new 
vessels developed in the newly-formed material, which has just become vascu- 
lar (Rokitansky) ; but Cohnheim has also shown that during the process of 
inflammation, at the same time that the white corpuscles permeate the veins, 
that red corpuscles make their way through the capillaries. In the ordinary 
course of internal 'inflammations, extravasations of blood are rare, and betoken 
an unfavorable state of the constitution generally, such as occurs in typhus 
fevers, in scurvy, in purpura, or in syphilis. The post-mortem evidence of 
such extravasations is the presence of a colored cicatrix at the spot of rupture 
and effusion, and the color is found to be due to the presence of hsematoidin, 
generally in the form of a mass of aggregate crystals, composed of minute 
rhombic columns, and which may be considered as the regular typical ultimate 
form into which hsematin is converted in any part of the body where consid- 
erable masses of extravasated blood continue to lie for any length of time, e. g., 
apoplectic clots, and coagula in the Graefian vesicle of the ovum after men- 
struation (Virchow). 

Mr. Paget correctly observes that we must not confound with hemorrhages 
the cases in which the inflammatory products are merely blood-stained, i. e., 
have acquired a more or less deep tinge of blood, through the oozing of some 
of its dissolved coloring matter. The natural color of inflammatory new for- 
mations is grayish or yellowish-white, and even when they have become vas- 
cular, their opacity in the recent state prevents their having any uniform tint 
of redness visible to the naked eye. When inflammatory products present 
the tinge of redness, it is either because of hemorrhage into them, or because 
they have imbibed the dissolved coloring matter of the blood ; and when this 
imbibition happens during life, or soon after death, it is important, as imply- 
ing a cachectic, ill-maintained condition of the blood, in which condition the 
coloring matter of the corpuscles becomes unnaturally soluble. 

3. Inflammatory Lymph or Fibrin. — This product is so named to distinguish 
it from the lymph in the lymphatic vessels, with which it is probably not 
Identical (Paget). It is a characteristic primary product of the inflamma- 



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TYPICAL FORMS OF GROWTH IN LYMPH. 83 

tory process, and was called originally "lymph," or " coagulable lymph;" and 
more recently it has been called "exudation," or "fibrinous" or "inflammatory 
exudation." "It is at first," says Mr. Paget, "probably always a pellucid 
liquid exudation which passes through the bloodvessels" — " sweats through 
them," as Simon hath it, — " and especially through the capillaries of the in- 
flamed part. Its most characteristic general properties are, that it may become 
a nidus-substance, capable of taking some share, or of assisting in promoting the 
growth of new elements like the natural connective tissue of the body." But 
the nature of the products of this development in the " inflammatory lymph" 
varies much, according to the part and the state of the constitution; and 
accordingly Bennett attempts to distinguish the products of simple exudation 
from those of tuberculous and cancerous exudations. The typical elementary 
forms which may grow amongst inflammatory lymph vary according to a 
much greater variety of circumstances. The circumstances which tend to 
modify the type of the inflammatory process, or impart to it a particular ten- 
dency in respect to the nature of the productive material, may be shortly 
stated as follows : 

1. The nature of the tissue in which the inflammation takes place. 

2. The period at which the product is examined after exudation has taken 
place and growth commenced. 

3. The state of the blood, and the nature of the zymotic or constitutional 
morbid state which may be associated with the inflammation. 

4. The amount of vascularity which the affijcted part retains. 

5. The amount of the local exudation, and the extent of healthy tissue 
implicated. 

6. The suddenness of the phenomena of exudation and of growth. 

7. The persistence of the inflammatory state in its vicinity. 

8. The amount of fluidity, serum, serous efiusion, blood, or mucus, asso- 
ciated with the inflammatory lymph. 

These are the chief circumstances which determine and modify the elemen- 
tary forms which may grow amongst the "inflammatory lymph," and which 
may advance to further development, or to degeneration. These circum- 
stances, severally, or more or less collectively, influence the difierent stages 
of progression, by which the local lesion of the inflammatory process may 
ultimately terminate in resolution, in permanent organic mischief, in death of 
the parts involved, or in death of the patient. 

There are several typical forms, especially found growing amongst the "in- 
flammatory lymph," and in the growth of which the material of the lymph 
may take some share — namely, the granular, molecular, or fibrillated develop- 
ment ot fibrinous products and corpuscular forms. 

Kokitansky describes these typical forms by the terms "fibrinous" and 
" croupous" and Dr. C. J. B. Williams by the names of "plastic" and " aplastic." 
Examples of each variety may illustrate the application of the terms. To the 
fibrinous or plastic variety belong the serous effusions already referred to, and 
perhaps also the granular, molecular, or fibrillated growths. The corpuscular, 
croupous, or aplastic forms of lymph are represented by those growths which 
never become consolidated, as in the early-formed contents of vesicles in vac- 
cinia and herpes; in the fiuid of blisters raised in cachectic patients; in some 
instances of pii&umonia; and in some forms of inflammation of serous mem- 
branes. In by far the larger number of inflammatory products these typical 
forms are mixed in various proportions ; and the larger the proportion of cor- 
puscles in new growth, the greater is the probability of suppuration, or of some 
other degenerative process, and the more tardy is any process of development 
into tissue, such as that of adhesions, indurations, and the like. In other 
words, the preponderance of granules, molecules, and fibrillated material in 
the new growth, is generally characteristic of the " adhesive or lymphy inflam- 
mations;" the preponderance of corpuscles, or their sole existence in a liquid 

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84 TOPICS RELATIVE. TO PATHOLOGY. 

medium, is a general feature of the "suppurative inflammation." The hard- 
ness of inflamed parts is due to the former of these typical forms of inflamma- 
tion, and is exemplified in the case of a phlegmon or hoil before it suppurates ; 
as also in a lung in a state of hepatization, when its textures are inclosed by 
lymph, "just as the stones of a wall are by the cement;" also in the harden- 
ing of a chancre. 

On the surfaces of inflamed membranes the new fibrinous growth forms a 
layer of a membranous firmness or consistence, to which the name of false, 
adventitious, or pseudo-membrane has been given. By this new growth the 
naturally opposed surfaces of parts which are inflamed are apt to adhere. 
This is commonly seen to be the case between such serous surfaces as the 
pleurae, the pericardium, the peritoneum, or the edges of a wound. The inflam- 
mation associated with this organization- is sometimes called "adhesive inflam- 
mation;" and Dr. John Thomson ascertained that this growth and organization 
might be efiected between the surfaces of wounds in less than four hours after 
they were inflicted. 

On the surfaces of mucous membranes may generally be seen the " corpus- 
cular" typical form of new growth as a result of inflammation. It has little 
tendency to cohere, but grows in films, gelatinous masses, shreds, patches, or 
delicate casts of the surface upon which it was formed. The new growths in 
chronic catarrh of the intestines are an example ; so are the membranes some- 
times passed from the cavity of the uterus, and called dysmenorrhwal mem- 
branes. In the " adhesive" form of inflammation the new growth of granules 
or of molecules may ultimately assume the form of fibrous tissue interstitial 
to the textural elements inflamed. Examples of this organization are seen in 
the laminated and nodular thickening of the capsules of the spleen, the thick- 
ening and induration of the periosteum, or the capsule of the hip-joint in 
chronic arthritis ; and by,virtue of the peculiar tendency to contraction which 
fibrinous products possess, the contractions of parts are to be explained which 
have been the seat of such a form of inflammation. 

There are instances also in which the new growth assumes the form of adi- 
pose tissue, elastic tissue, and epithelium (Kiekes, Viechow, Paget) ; and 
bone is a very frequent ulterior change which it assumes, especially when the 
new growth is interstitial to fibrous tissue ; but these ulterior events only happen 
after the inflammatory process has ceased in the part. So long as the inflam- 
matory phenomena continue, the tendency of the new growth is to assume the 
corpuscular form, such as pus, rather than the more adhesive forms of organi- 
zation. Hence rapid organization accompanies, as a general rule, a minor 
degree of action ; and by depressing the action of a part, we tend to prevent 
the threatened occurrence of suppuration. 

, The existence of the inflammatory state, associated with an interstitial exu- 
dation, influences the simplest corpuscuktr forms of organization. Lymph-cells, 
or simple primordial forms, occur, which are represented by the corpuscles of 
chyle, lymph, the white corpuscles of the blood, and by those of granula- 
tions on the surface of a wound. These simple cells become developed amongst 
the lymph while it is still fluid, transparent, and apparently homogeneous. 
The first discernible organic form in the lymph oi herpes, for example, is that 
of a mass of soft, colorless, or grayish-white corpuscles, about j-^th or ^-5^11*^ 
of an inch in diameter, round or oval, pellucid, but appearing, as if through 
irregularities of its surface, dimly nebulous or wrinkled. It does not look 
granular, nor is it formed by an aggregation of granules ; nor in its earliest 
state, can any cell-wall be clearly demonstrated, or any nucleus on adding 
water. In a few hours, however, a pellucid membrane appears to have grown 
over its surface, permeable by water, which raises up part of it like a clear 
vesicle, while the contained mass retreats or subsides to the lower part of the 
inclosure, and appears more nebulous or grumous than before. A nucleus ulti- 
mately forms, and can be distinguished in this mass (Paget). 



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ABSOEPTION OF LYMPH. 85 

From these primordial cell-forms in the lymph either the adhesive or more 
corpuscular forms of organization may proceed ; and all the various forms of 
corpuscles described by authors as plastic cells, fibre cells, caudate cells, or 
fibro-plastic cells, and some forms of filaments, are developed from the ger- 
minal matter of the surrounding tissue by continuous development. Also, 
from the 'development of the primordial granules, corpuscles, or cells, all those 
elementary forms proceed which are known as "pus-corpuscles," "granule-cells," 
"compound gramde-masses or cells," "inflammatory globules," and much of the 
molecular debris-like matter that makes inflammatory efl[usions turbid. 

The modes of growth as well as of degeneration are well described by Mr. 
Paget, from whose work on Surgical Pathology the following examples and 
illustrations are chiefly taken : 

1. The lymph may simply wither or waste, as may be noticed in the vege- 
tations on the valves of the heart or large arteries, when they become yellow, 
stiff", horny, elastic, and nearly transparent ; or in the lymph deposited over a 
compressed lung, associated with empyema or hydrothorax. 

2. The fibrin of lymph may undergo changes similar to what is known as 
fatty degeneration, — changes similar to those which occur in the primordial 
lymph-cell when it is transformed into pus. The two changes generally go on 
together. To the former change — namely, the fatty-like degeneration of the 
fibrin — Mr. Paget gives the name of " liquefactive degeneration:" the solid 
fibrin of inflammatory lymph that becomes again liquid when suppuration 
takes place, as may be observed in a hard mass of inflamed texture when it 
becomes sol^. 

This is a degeneration which brings the new growth into a state favorable 
for its absorption, or to the resolution of an inflammation. Examples of such 
an absorption may be seen in rheumatic iritis, and the observations of Dr. 
Kirkes on the rarity of adhesions of the pericardium in comparison with the 
frequency of pericarditis may also be explained in this way. 

3. Melanic degeneration of lymph and new growths is not unfrequent, as in 
peritonitis. 

Concurrent with these degenerations of the lymph-granules and molecules 
are the degenerations of the corpuscular elements. 

1. They may wither, as in the dried-up pus of chronic abscesses. 

2. The fatty degeneration of cells is said to be shown in their transition to 
the granule-cell, known also as the inflammatory globule of Gluge, or the exuda- 
tion-corpuscle of Bennett. The history of the formation or growth of these 
corpuscles is still doubtful. 

The description of them, as originally given by Gluge, in describing the 
alterations of blood in inflamed parts, is as follows : 

He observes "that the blood-globules lose their tegument and their color. 
Their inner substance alone remains, which, however, does not remain soli- 
tary ; but by means of a whitish connecting material the masses become 
agglomerated, and form dense, opaque, round groups, containing on an aver- 
age from twenty to thirty of the smaller bodies, which, examined singly, are 
quite light and transparent. By means of pressure or acetic acid the asso- 
ciated granules break down into the individual bodies, and we see that the 
opacity is merely owing to the association. The associated bodies have a 
diameter in the mass of from -gJgth to ^'gth of a millimetre ; the single gran- 
ules are from -j-J^j-th to -flcth of a millimetre. These associated bodies," says 
Gluge, "I have seen in the bloodvessels, so that we have not here to do with 
a fluid which, transuding through the coats of the bloodvessels, is changed 
into granules. They escape by bursting the capillaries." 

That this cell or corpuscle is formed within as well as without the blood- 
vessels, is apparent from an examination of inflammatory lungs or brain-sub- 

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86 TOPICS EELATIVB TO PATHOLOGY. 

stance. The corpuscles may be seen to coat the bloodvessels exteriorly and 
interiorly to their walls ; and the formation of the corpuscle of Gluge can also 
be traced through stages of development, as described by Vogel, Bennett, 
Kolliker, Hasse, and myself; as well as through stages of degeneration from 
the normal state of some corpuscular elements (textural or morbid), the occur- 
rence of which has been described by Reinhardt, Dr. Andrew Clark, Dr. W. 
T. Gairdner, and Mr. Paget. 

The essential ingredient of which the compound granule-cell is composed 
appears to be oily or fatty matter ; and these cells vary considerably in their 
appearance, according to the fineness with which this matter is divided. In 
some the oil-drops are large, in others they are small and quite granular. 
They are by no means confined to inflammatory parts. Kolliker, in examin- 
ing morbid products in an animal, has seen oval blood-discs included in these 
corpuscles, showing that the cell-membrane may be in some instances a sub- 
sequent formation in their progressive development. This view of their na- 
ture would imply that a number of the original oil or fluid granules come 
into contact with each other, and cohere into a glomerulus, which subse- 
quently becomes invested with a membrane, and constitutes a cell, the con- 
tents of which gradually undergo some morphological process by which they 
are resolved, and ultimately pass into the circulation (Simon). 

My own observations on this point, published in, 1849, and chiefly made 
upon inflamed pulmonary tissue, led me to express the same result, as to the 
nature of this compound corpuscular development, in the following statement ; 

"1. The formation of clear, transparent, non-nucleated cells may be ob- 
served. 

" The formation of cells with a nucleus and nucleolus are seen, differing 
from pus-corpuscles in their large size, and in having a single nucleus. These 
are formed in the fluid of coagulated exuded matter, and become gradually 
filled by minute granules, which, when few in number, readily admit of the 
nucleus being seen. Subsequently, however, they conceal it ; and the origi- 
nally smooth cell-membrane becomes rugged, the granular cell appearing as 
a spherical agglomeration of granules. Subsequently the cell-wall appears 
to vanish, the inclosed granules to separate from one another, and to fall into 
irregu^r heaps" {Edin. Med. Journal, No. 178, for 1849). 

The following are the general facts connected with the appearance of these 
corpuscles : 

"1. They are formed in greatest abundance during the first stage of the 
exudation (the second stage of pneumonia, according to Laennec). 

" 2. As long as the capillary circulation is going on, and before complete 
stagnation has taken place. 

"3- When the redness and condensation are the greatest, the corpuscles 
begin to disappear, or are not seen. 

" 4. They disappear altogether as the red softening passes into gray, be- 
coming liquid. 

" 6. They are imperfectly formed, or not at all, in the deposits that occur 
durmg the progress of typhvis fever or typhoid fever." 

Associating these observations with the descriptions of Mr. Paget relative 
to the liquefaction of fibrin,— with those also of Zwicky and Gulliver, who 
found these corpuscles in the softened apex or centre of arterial clots,— with 
those of Simon, who states that they are often found in the fibrinous clots of 
veias,— with their occurrence in the mammary secretion, in the softened parts 
of encephaloid cancer, in the vicinity of apoplectic eflTusions, and that gen- 
erally they are extremely apt to be present where blood, or the products of 
exudation or secretion are undergoing absorption,— does it not appear proba- 

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THE INFLAMMATORY TYPE OF FEVER. 87 

ble, moreover,, from the lucid description given by Mr. Paget (when he says 
that during the formation of these corpuscles " they present a gradual in- 
crease of shining black-edged particles, like minute oil-drops, which accumu- 
late in the cell-cavity, and increase in number, and sometimes in size also, till 
they fill it"), that these compound granular cells, when associated with in- 
flammatory products, fulfil a very important function, as the media through 
which the liquefied, softened, and disintegrated products of inflammation are 
gradually absorbed? 

The observations of Keinhardt, Dr. Andrew Clark, Paget, and Gairdner, 
also place it beyond a doubt, that compound granular cells may result from a 
fatty degeneration of the textural cells of a part ; just as calcareous or pig- 
mental degenerations occur, and which are common to primordial cells. 
While there can be no doubt, therefore, that fatty degeneration of lymph or 
textural elements may lead to the appearance of compound granular cells, 
that process can scarcely be called degeneration which is associated with 
development, growth, and complete absorption, by which the indurated and 
confused parts of an inflammation, such as the solidified portions of a lung 
in pneumonia, are ultimately cleared up. 

Degenerate products are usually persistent, but the compound granule-cell 
is not. It seems to have an important function to perform in the removal of 
fluid, effete, or softened exudations, after which it too disappears. 

All these productive effects of inflammation, in the form of efilisions or 
exudations, contribute, ■»ith the greater abundance of blood, to the swelling 
which attends inflammation of a part. The effusion may collect within a 
shut-sac, as in synovial and serous inflammations ; or it infiltrates the solid 
organs. In mucous membranes the effusion is represented by the altered 
secretion which, as a catarrhal exudation, flows from its surface. The swell- 
ing in such cases is represented by the amplification of the epithelial layer ; 
and hence the interference of respiration which belongs to the beginning of 
acute bronchitis, the blocking up of the kidney tubes with modified cell- 
growth in scarlet fever, and the diminished stream of urine during the severity 
of gonorrhoea (Simon). It is these products of effusion and exudation which 
render inflamed parts so extremely juicy, so oedematous, that a cut or punc- 
ture into them during life allows the fluid to drain away long after hemor- 
rhage has ceased. 

All these efl!usions of inflammation differ from the mere exudation of serum 
from liquor sanguinis in the nutrition of texture. " Their specific gravity is 
high. Their proportion of albumen is great ; and, when they are not puru- 
lent, they probably give a fibrinous coagulum" (Simon). 

Local and General Symptoms of Inflammation. — Redness, or at least 
increased afflux of blood, swelling, or at least textural productivity, pain, 
throbbing, increased sensibility, disorder of function, arrest and change of 
secretion, are the phenomena which are associated with the local morbid 
state, or with the textures in its immediate vicinity. Under all circumstances 
the inflammatory process involves a local production of heat accompanying 
the increased vital effort and the increased textural changes of inflammation. 
This has been recently proved to demonstration by the ingenious experiments 
of Mr. Simon and his colleague. Dr. Edmund Montgomery {A System of 
Surgery, second edition, edited by T. Holmes, M.A., vol. i, p. 20). If the local 
process of inflammation, however, is carried on upon a minute scale, or in 
certain tissues, one or other or more of these symptoms may be absent; if,- on 
the other hand, the local process proceeds on an extensive scale, and involves, 
important and delicate textures of vital importance, then we have much more 
unequivocal expression given, not only to local symptoms, but to coniplex 
morbid processes, affecting the constitution generally. Of these the chief are : 

I. Inflammatory Fever. — Of the constitutional symptoms, as they are termed,, 
the most prominent are those which indicate " inflammatory fever, sxjmptomatiG- 



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SS TOPICS RELATIVE TO PATHOLOGY. 

f&ver, or sympathetic fever." These constitutional symptoms are of the greatest 
importance, not only by indicating the nature of the disease, as \yhen the 
inflammation is connected with an internal organ removed from sight and 
touch ; but they are highly important as a guide to treatment. The premoni- 
tory symptoms of coldness and shivering are usually very decided, but not of 
long duration. They are succeeded by a stage of reaction. The pulse is then 
hard and swift. There is thirst and greatly increased heat of surface. The 
secretions and the appetite may not at first vary much from the normal state, 
but on the whole are diminished. Exhaustion and emaciation do not proceed 
rapidly. This fever is pre-eminently one of strong reaction and vascular 
excitement, and these characteristics may be said to constitute its type. 

A most mmute description of the disorder of the general frame by inflam- 
matory fever, according to its effect on the systems of the body, is thus con-' 
densed from the account given by the late Professor James Miller (Prindples 
of Surgery, p. 39) : 

(1.) The Nervom System. There are aching, dull pains in the loins a,nd 
limbs, restlessness, and much discomfort. The will and the power of exertion 
are diminished. Anxiety or foreboding of evil is felt and expressed upon the 
countenance. The head is generally hot, the face flushed, the eyes suffused, 
and the skin hot and dry. Special sensation is at first exalted, but after- 

. wards the intellectual functions become more and more disturbed. Ulti- 
mately delirium is established, and coma may ensue. (2.) The Vascular Sys- 
tem. The pulse ranges from 80 to 130, or more, and the heart's action is 
proportionally rapid. The pulse is hard, rolling like a cord below the finger, 
and yielding but little to its pressure ; or an irregularity of movement in the 
artery may exist, and thus a thrill or jar is imparted to the finger. There is 
increased fulness, as if the vessel were itself enlarged, and held a larger quan- 
tity of blood at each impulse ; the heart is acting not only niore rapidly, but 
more powerfully than in health, and the circulation is truly accelerated. 
Frequency, hardness, and thrilling, are seldom, if ever, absent ; but fulness 
may be wanting, and the pulse may be small instead of full. This modifica- 
tion is chiefly observed during serous inflammatory action, affecting important 
internal organs situated in the abdominal region. Hence it is sometimes 
termed the abdominal pulse ; the artery resembling a hard, thrilling thread, 
rather than a cord. This pulse always exists in connection with great nervous 
depression, and debilitated, though rapid, cardiac action ; to which circum- 
stance its smallness is probably due. In affections of the brain, on the other 
hand, producing coma, the pulse is commonly slow and full ; the suspension 
of cerebral influence appearing to diminish the rapidity, without affecting 
the. force, of the heart's action. There are idiosyncrasies also to be taken 
into account. The pulse ma,y be naturally slow or rapid — ^fifty or ninety ; 
and this must be allowed for, when previous inquiry has satisfied us that the 
patient is the subject of such peculiarity. (3.) The Respiratory. Respiration 
is quickened ; the breath is felt to be hotter than usual ; and an oppression is 
complained of in the chest. (4.) The Digestive. The tongue may be loaded, 
white, and moist ; or the edges and central tip may be red and dry : the latter 
is probably the more frequent combination. (5.) The Secerning. The secre- 
tions and excretions in general are materially diminished. "The bowels are 
constipated — mainly from want of mucous secretion from their lining mem- 
brane ; the skin is hot and dry ; the mouth is parched ; the urine is scanty, 
high-colored, generally acid, sparingly aqueous, and holding much saline 
■matter, with comparatively little urea, in solution. (6.) The Nutritive. Diges- 
tion is interrupted ; so is assimilation ; as the fever advances, so does emacia- 
tion ; and strength is more and more prostrate. 

Chilliness, often amounting to shivering, marks the date of the febrile dis- 
turbance; and rigors more frequently attend the commencement of spontaneous 
inflammation than of inflammation caused by external injury. 

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THE INFLAMMATORY TYPE OF FEVER. 89 

The essential fact of inflammation fever is, that in proportion as any con- 
siderable part of the body becomes acutely inflamed, the patient's blood in- 
variably rises in temperature above 98° Fahr. ; and regarding this constitu- 
tional febrile state characteristic of inflammation, some important general 
conclusions, especially insisted on by Dr. Alison and Dr. Watson, may be 
thus shortly stated : 

(1.) It is to be observed that there is no fixed relation between the degree 
or intensity of internal inflammations and the constitutional fever attending 
them ; nor is the fever always proportioned in its degree of violence to either 
the size or importance of the part inflamed. In some cases, writes Dr. Alison, 
where we are sure that we have had inflammation going on under our inspec- 
tion, to extensive eflfusion of pus, the pvilse has been feeble, the skm cool and 
damp, and the patient exhausted and faint on the slightest exertion ; while 
in others there is high and more inflammatory fever, and in some of these 
the organ inflamed has been so to no extent, and its function comparatively 
little aflected, but yet the patient has become comatose nearly as in typhus, 
and died so. Laennec makes an observation of a similar kind, and Dr. 
Watson observes that the fever may be high and very strongly marked in 
that common complaint, the quinsy, cynanche tonsillaris, or tonsillia, which 
can scarcely ever be said to imply much danger. (2.) The situation, the 
extent, and the degree of the local inflammation being the same, the fever 
commonly runs higher in young and in plethoric persons, and in those of 
sanguine temperament, than under opposite conditions. (3.) Inflammatory 
fever is modified in its expression, and especially in the characters of the 
pulse, by the nature of the part which is inflamed. This ha§ been already 
alluded to in regard to inflammations of the abdomen, where the action of the 
heart is depressed, and the pulse is changed accordingly, tending to death by 
asthenia ; and also in regard to the brain, when the mode of death tends to 
be by coma, the pulse being slow, labored, and full. (4.) The type of the 
inflammatory fever is very much modified by constitutional circumstances, 
such as the previous habits of the patient, and whether any zymotic disease 
is associated with the local inflammation. (5.) The inflammatory fever 
undergoes a further change of type (a) when suppuration takes place ; (b) 
when it continues long ; and (c) when mortification or gangrene occurs to a 
large extent. (6.) The febrile state follows generally the local disease ; but, 
(7.) There is also good reason to believe that the pyrexial condition, and the 
condition of inflammation in a part, may be excited in some instances con- 
jointly ; or, at all events, their periods of commencement may correspond so 
closely that it is difiicult to conceive that one is the eifect of the other. Obser- 
vations are much wanted as to the exact ranges of temperature, as measured 
by the thermometer, in cases of inflammatory fever, and so to verify or set 
aside such general statements (see Bilroth, in Year-Booh of Syden. Society for 
1861). 

When inflammation proceeds to suppuration, a severe paroxysm of shiver- 
ing is often the first indication of the formation of the pus, and the character 
of the fever undergoes a great alteration from that just described. The degree 
of the fever varies greatly even in this case, for a most copious formation of 
pus may take place from a mucous membrane, as that of the bronchi or 
urethra, and yet the constitution may hardly sufier in any appreciable degree; 
while a trifling amount of pus from a serous membrane may be associated 
with a fatal fever. 

In any case the character of the fever depends in a great measure on the 
constitution of the patient. If that be good, the fever is attended with a 
white tongue, with little tendency to become brown, also with much heat, and 
a full, strong pulse. On the contrary, if the patient's constitution be broken 
or impaired, the fever is of a low type — asthenic, as it is called. The event 
o{ suppuration is generally marked by a rigor of greater or less severity, while 

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90 TOPICS KELATIVE TO PATHOLOGYi 

the fever hitherto has been sthenic. It is the occurrence of the rigor in the 
course of the inflammatory febrile state which gives it prominence and im- 
portance. It generally attracts the attention of the patient, and indicates to 
the physician that pus has been produced in the part or organ inflamed. As 
soon as suppuration is complete, and the abscess ripens, or pus approaches a 
surface to be discharged, and especially if any important organ is its seat, the 
fever tends to become asthenic, with a brown tongue and a rapid pulse, while 
the local pain in a great measure subsides. At this period the abscess must 
open spontaneously, or be opened by art, otherwise the patient may be in 
danger. The opening of the abscess, though attended with much pain from 
the contracting of the inflamed walls, is usually followed by relief of all the 
constitutional symptoms; the pulse rises, the tongue cleans, the appetite 
returns, and a visible and immediate amendment takes place. If, however, 
the patient has been exhausted by his sufferings in the earlier stages of the 
disease, the relief aflfbrded is but transient, the pus degenerates into sanies, or 
is altogether suppressed, the fever changes its type, and the patient sinks, too 
enfeebled to establish the reparatory process. 

II. Typhoid Fever. — The type oi fever during inflammation, known by this 
name, is asthenic or adynamic. Feeble and more feeble the patient becomes ; 
the pulse sinks ; there is great impairment, of the heart's action, and tendency 
to collapse ; the features become pinched, shrunken, damp, and ghastly ; and 
the skin is covered with a cold and clammy perspiration. Sometimes these 
adynamic characters may pass into that typhoid state in which nervous symp- 
toms, such as delirium, somnolence, and tremors prevail. These characters 
are known as nervous or ataxic. The tongue becomes dry, black, and tremu- 
lous, sordes cover the teeth, and harden on the lips and angles of the mouth. 
Low muttering delirium, stupor, or coma prevail ; tremors affect the volun- 
tary muscles, and .the faeces and urine pass unnoticed. This form of fever sets 
in as a consequence of some untoward or unhealthy tendency of the inflamma- 
tory process, such as when mortification of the part occurs. Any cause, how- 
ever, by which the system becomes extensively vitiated, will bring about this 
form of fever. It is not necessary that the part should die. Putrescence of 
the infiltrated exudations in the inflamed part poison the fluids circulating 
amongst them, and so, by absorption, riiay induce the typhoid state. If this 
happens with an internal organ, the event is generally indicated by a sudden 
cessation of all pain, at which the patient often appears very happy, and even 
joyous, while to the experienced physician its sudden cessation is assuredly an 
evil omen (Watson). The most important vital functions are deeply im- 
paired by a prolonged existence of this type of fever. It tends to death by a 
complete sinking of the circulation, and diminution and loss of animal heat ; 
or deepening stupor, with oppressed respiration, supervenes ; or the patient dies 
by a combination of both conditions, — asthenia and coma. 

These are two distinct types or forms of fever, one or other of which is sure 
to be associated with inflammation. 

Causes of Inflammation. — These have been described by Mr. Simon as : 

(1.) Determining or exciting causes, arising from several sources, and hav- 
ing different modes of operation. 

(2.) Predisposing causes or influences. Inflammation does not take place 
without an irritating stimulus ; irritation being the starting-point in every 
form of inflammation. The determining causes of irritation, classified accord- 
ing to the source whence they come, are : 

1. Acts of mechanical and chemical violence inflicted from without — e. </., cuts, 
stabs, bruises, lacerations, abrasions, fractures, dislocations, burns, the action 
of caustics, or other chemical agents. 

2. Lodgment of matters foreign to the tissue — e.- g., splinters, bullets, morbid 
products, retained excreta — becoming irritant to parts and cavities containing 
them ; a bladder imperfectly relieved of urine — as in chronic paralysis ; re- 

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DEFINITION OF ULCERATIVE INFLAMMATION. 91 

tained and decomposing excrement in balls or knobs (scybaloi), irritating the 
mucous membrane of the colon ; concretions of blood — as in retro-uterine or 
pelvic hsematocele ; masses of tubercle ; dead. tissue; a dislocated crystalline 
lens ; a sequestrum of dead bone : all tend by contact, as foreign bodies, to 
provoke inflammation -within a certain radius of their influence. 

3. An altered state of the local nerves, as "when injuries or diseases of the oph- 
thalmic division of the fifth nerve lead to injection and inflammation of the 
conjunctiva, clouding and ulceration of the cornea, final destruction of the 
globe of the eye, and sometimes to ulceration of neighboring integument. 
Similarly, lesions of the pneumogastric nerve may induce pneumonia. 

In explanation of how the nerve-influence acts, there are some grounds for 
belief that certain portions of the nerve cords consist of centrifugal fibres ex- 
ercising a special " trophic" function ; and that it is probable they may be 
subject to some reflex action, as when a carious tooth produces superficial 
sloughing of the cheek, or ulceration of the neck (Salter, in Ghiy's Hospital 
Reports, vol. xiii, third series. Simon). 

4. Abiwrmal properties of the droulating blood, such as deficiencies in its 
constitution, or from being charged with some specific irritant. The " poor 
blood " of persons who are ill-nourished is popularly believed to be a source of 
inflammation. The tissues are badly nourished, so that wounds or injuries on 
them tend to inflame and fester, rather than to heal, and that out of proportion 
to their injury or hurt. Privation of food is therefore an active determining 
cause of inflammatioij ; leading, most probably, to a certain quantity of tex- 
tural death as the direct result of the privation. 

The action of specific irritants with which blood may be charged, and 
which lead to inflammation, may be exemplified in the fact, that arsenic ap- 
plied to an external sore produces its characteristic inflammation on the mu- 
cous membrane of the stomach, just as efficiently as if it had been swallowed,. 
So will the application of a cantharides blister produce strangury. From 
the contact of blood thus poisoned, the stomach or the kidneys inflame ; and 
so also serous inflammations flow from blood in Bright's disease, being poi- 
soned with the elements of uneliminated urine, acting as an irritant to the 
serous membranes. 

5. Direct contagion causes inflammation, as when the material secretion from 
a vaccine vesicle or a primary syphilitic sore, or from small-pox, is inserted 
into the skin by a scratch, and produces a train of inflammatory phenomena 
peculiar to each kind of inoculation. Also, when gonorrhoeal pus comes into 
contact with a healthy urethra, inflammation, with a flow of similar specific 
pus, forthwith commences. 

The predisposing causes of inflammation are certain influences which 
co-operate with the determining causes. They embrace those influences which 
make one man at one time apter than another to initiate an inflammatory 
disease, or special forms or varieties of -inflammation. Examples of such 
influences, Simon states, are to be found in chronic inanition, exhaustive 
diseases of old age, local disease of arteries, local obstruction of veins, local 
defects of innervation, previous inflammation in a part, overfeeding of the 
body, overstimulation from alcoholic drinks, ingestion, by breathing or other- 
wise decomposing organic matters, climatic influences, such as heat. 

ULCERATIVE INFLAMMATION. 

Latin Eq., Inflammatio Exuleerans ; French Eq , I. Ulcerative; German Eq,, 
Geschwiirige Entziindung ; Italian Eq , Inflammazione Ulcerosa. 

Definition A form of inflammation which, eventually approaching a cuta- 
neous or mucous surface, induces a breaking up of the surface, and the formation 
of what is termed an uker. 

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92 TOPICS RELATIVE TO PATHOLOGY. 

Pathology, — When the process of inflammation takes place beneath a sur- 
face, eventually that surface gives way, or is directly transformed into a soft 
diffluent mass. A mode of suppuration or pus-formation is thus established, 
and granulations appear. These consist of a tissue, where, in a small quantity 
of soft intercellular substance, round cell-elements are imbedded, proportionate 
in quantity to the proliferation of the granulations. The nearer the surface 
is approached, the more do the cells present divisions in their nuclei, which, 
in the deeper parts, were mostly uni-nucleated before ; and quite on the sur- 
face they cannot be distinguished from pus-corpuscles. If this mode of growth 
or proliferation continues abundant, the mass keeps constantly breaking up, 
the cells pour themselves out upon the surface, and a destruction takes place, 
which, making deeper and deeper inroads into the tissue, throws up more and 
more of its cells and dfebris upon the surface. Thus an open condition of the 
surface is brought about, to which the name of an uker is given. The term 
ulceration is now being restricted so as to express the removal of the superfi- 
cial or exposed particles of inflamed parts ; but when epithelium or epidermis 
of an inflamed part is alone removed, and none of the vascular or proper tissue 
beneath it, then the result is a niere "abrasion" or "excoriation" (Paget). 
■ Three processes thus progress simultaneously in order to eflect ulceration, 
namely : (1.) An exudation of inflammatory lymph and serum surrounds the 
mass of young cells, which constantly continue to grow and to break up (pro- 
liferation). (2.) Cells are thus continually growing on the surface, to be car- 
ried ofi'by a fresh exudation. (3.) Liquefaction of the gelatinous interstitial 
material supervenes, and so destruction of tissue takes place continuously. 
Thus ulceration advances. 

Ulcerative inflammation is thus always attended by a loss of substance, a 
destruction of parts, and a more or less abundant secretion of a puriform, 
ichorous, fetid, sanious, or an otherwise variously-colored fluid ; but in the 
midst of this destruction and death of parts, the growth of granulations may 
eventually predominate as inflammation subsides. Thus the ulcer heals by 
granulation. 

Granulation, therefore, is one of the modes in which a wound, or sore, or a 
part previously acutely inflamed, may heal. It is then said to do so by 
" second intention," and is always a reparative process. Granulation may 
occur with or without suppuration. The first mode is extremely common. 
The latter is occasionally seen in the healing of syphilitic maculae and ulcers 
of the cornea ; and Mr. Hunter conceives he once met with it in the union of 
a broken thigh-bone. 

Granulation is associated with an exudation of inflammatory lymph, into 
which old vessels extend, and new ones are formed. A new surface thus 
results, which is " granular " — the granule or granulation being a small coni- 
cal tumor or growth, composed of a mesh of terminal loops, formed by capil- 
lary vessels shooting into the efiiised lymph. The figure and color of the 
granulation are determined by the state of the circulation ; when that is feeble 
and inclined to' stagnate, the granulation is broad, flat, and spongy, and either 
pale or of a livid hue ; when, on the contrary, it is vigorous, the granulation is 
conical or acuminated, and of a bright-red tint (Tea vers). The vessels pro- 
longed into the granulation are more or less tortuous, and so numerous as to 
require a high magnifying power to exhibit their distinctness after successful 
injection. These vessels become contracted to obliteration as the period of 
cicatrization approaches. Granulation may take place from a surface, or from 
the sides of an abscess. If from the cutaneous tissue, the sore heals by a pro- 
cess of skinning ; the skin always springing from the edges of the wound. 
Again, if granulations spring from the walls of an abscess, their opposite sur- 
faces may unite. Granulations sometimes form with great rapidity. Mr. 
Hunter has seen, after trephining a patient, the dura mater strongly united 
to the scalp in twenty-four hours. Granulations, however, have not in all 

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SITES OF ULCERATIVE INFLAMMATION. 93 

cases an equal disposition to unite. Thus the granulations of fistulous ab- 
scesses are little prone to adhere, their surfaces being often as difficult to unite 
as those of a mucous membrane ; indeed, it is often impossible to produce ad- 
hesion except by exciting a considerable inflammation. A part having healed 
by granulation, uniformly contracts. This contractile force is so great, that 
although the sore made by the amputation of a thigh is seldom less than seven 
or eight inches in diameter, yet the cicatrix left on healing is hardly more 
than an inch or an inch and a half. From this cause we find, in parts that 
have been the seat of abscess, a marked depression at the point of cicatri- 
zation. 

The reproductive energy of parts which heal by granulation, however, is not 
great. It is rare that the original tissue is perfectly reproduced. No fat, for 
instance, is regenerated in ulcerated adipose tissues ; a muscle being divided, 
unites by a cicatrix of connective tissue, no muscular fibre being reproduced ; 
and a divided cartilage unites by tough fibrous tissue, but not by a cartilagi- 
nous bond of union. The skin, when destroyed, may be reproduced, especially 
by the method of grafting or transplantation of germs of the rete muoosum, as a 
good imitation. After small-pox, the rete mueosum is either slow in forming 
or never forms at all, so that the cicatrix or pit remains whiter than natural. 
Neither the smooth muscular fibres, nor any of the glandular structures of the 
skin, are formed in its scars ; but its fibro-areolar and elastic tissues, its papil- 
lae, and epidermis, are all well formed in them. The reparation of the mucous 
membrane is equally imperfect, the villi being always wanting. The repara- 
tion of a flat bone, such as the cranium, is so slow, that ten, twenty, and even 
fifty years pass away before a small trephine hole is filled up with bony mat- 
ter. In like manner a healed cavity of the lungs is always marked by a cica- 
trix of areolar tissue altogether different from the original structure ; neither, 
as far as we know, is the proper tissue of the liver, of the spleen, or of the kid- 
ney, restored. A nerve simply divided is united by nervous matter in about 
twelve months or more ; and the union is quicker and better in all tissues if 
air is excluded from the healing of the part. 

It is a rule of all cicatrices that the newly-formed part is harder and of 
greater density than the original structure. Muscle, for instance, unites by 
coarse, dense, connective tissue ; tendon most frequently by a harder and less 
pliant, but not tougher tissue, and sometimes by bone ; and bone after a frac- 
ture is a more compact substance, and contains more phosphate of lime than 
before the accident ; but, notwithstanding this addition, the new bond of 
union is not so strong, nor the living actions so energetic, as in the original 
structure. For when the constitution becomes enfeebled by severe disease, of 
a scorbutic kind especially, an old sore has been known to open, and the ends 
of a once-broken bone again to separate. It is equally a rule that a part 
having been once inflamed, the liability of the part to that form of inflamma- 
tion is greatly increased ; and also, when new membranes or tissues have 
formed, that these tissues are infinitely more prone to disease than the originat 
membrane. 

The sites of ulcerative inflammation with which the physician has most 
frequently to contend, besides the skin, are especially the cervix uteri, duode- 
num, larynx, pharynx, oesophagus, stomach, intestines, bladder. The form 
and mode of ulceration in each of these parts is peculiarly influenced by the 
anatomical nature of the textures implicated. Sometimes a distinct and 
limited slough is first cast ofi" and leaves the ulceration beneath — sloughing 
ulcers — as in those of dysentery, where the smallest and most superficial 
ulcers of the gut are preceded by the death and detachment of portions of the 
mucous membrane, with its epithelial investment (Baly). 



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94 TOPICS RELATIVE TO PATHOLOGY. 



SUPPUEATIVE INFLAMMATION. 

Latin Eq., Jnflammalio Suppurans; French Eq., I. Suppurative; German Eq., 
Eiierige Eniziindung ; Italian Eq , Inflammazione Purukida. 

Definition. — A form of inflammation, reeulting in the formation of pus. 

Pathology. — One of the most frequent and important results of inflamma- 
tion is the formation of pus by the growth of pus-cells. If a phlegmon or 
boil be observed, when it is a firm, hard, and solid mass of texture and exu- 
dation, we may feel in a few days that the solid mass has become fluid, and 
that it has not increased in bulk. The solidity and hardness are due to the 
inflammatory Changes and efiusion, the softening is due to the growth of pus- 
cells developed from the germinal elements of surrounding tissue (Virchow, 
Beale). So it is with the cells of vesicular eruptions which become pustular. 
The new cells there also become pus-cells — a change which may be accom- 
plished in twelve hours, or sooner (Paget). The following circumstances 
point to the development of pus from pre-existing germinal matter, namely, 
that,^(l.) A preliminary lymph-cell cannot always be discerned ; (2.j The 
modification of the suppurative process, which occurs in the inflammation of 
mucous surfaces, where the formation of pus seems at once to take the place 
of the natural cell-growth, without any apparent distinction or alteration of 
the membranes of the mucous cells, corresponding in this instance to the most 
simple idea one can have of what Virchow terms parenchymatous inflammation, 
as described at p. 79. Ultimately the natural mucous secretion undergoes a 
change. The characteristic cells on its surface drop off in all stages of abor- 
tion. Impaired cohesion of parts results, — an invariable expression of the 
inflammatory tendency. The epithelial covering becomes less characteristic, 
and gradually declines to small and simple cells, mingled with many pri- 
mordial cells, which appear to have been hurried from the surface bfefore 
they had time to undergo their legitimate development into the perfect 
mucous cells. From this sketch of what occurs, "it will be obvious," as Mr. 
Simon writes, "that the anatomical distinction between pus and mucus must 
be as useless as the so-called chemical tests. Infinite gradations between the 
two destroy all practical value in such criteria. Mucus, a.? a copious fluid 
secretion, has no existence in health : the only natural secretion of a mucous 
membrane is its epithelium, which ought not to exist in quantity sufficient 
for any evident discharge. If the secretion be hurried, as in catarrh, it im- 
mediately begins to assume the forms and physical characters of pus, even to 
the splitting of its nuclei with acetic acid." In short, the essential process of 
inflammation has been established in the very cell itself, by the abnormal nutri- 
tive morphological relations which take place between it and the blood in the 
■ processes of lite. 

Inflammations of mucous membrane with a mucinous exudation (quite as 
characteristic of inflammation as fibrinous exudations) appertain to certain 
organs, e. g., the gastric catarrhal inflammations. Such mucus is loaded 
with mucin, as a characteristic product of the inflamed mucous membrane, 
and which gives the tenacious, stringy character to the discharge. 

Between healthy pus and healthy mucus there can thus be no confusion ; 
but there are conditions between tlie two which yield neither "praiseworthy" 
pus nor healthy mucus. 

Formation of Pus— Suppuration — Well-formed, perfectly elaborated pus 
is a smooth, viscid, yellowish or cream-colored fluid, specifically heavier than 
water, averaging generally about 1.030, having little or no smell, and of an 
alkaline reaction. Microscopically, it is seen to be composed of certain essen- 
tial constituents — namely, the pus-cell, and often minute clear particles, which 
seem to have some relation to the pus-cells as rudiments or nuclei of them. 



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FORMATION OF PUS. 95 

These constituents float in a fluid or serum called the liquor puris. The pus- 
cells are about -j-J-Q-th to so'ooth of an inch in diameter, pellucid, filled with 
semifluid albuminous contents, and sometimes containing a few minute oil- 
globules, which give the cells a granular appearance. Their shape appears 
to depend upon the density of the liquor puris. Sometimes a distinct, circular, 
dark-edged nucleus may be seen in the paler corpuscles, and sometimes two, 
or even three particles, like a divided nucleus. The minute clear particles 
often seen are not more than y^Jjoxjth of an inch in size. Such are the com- 
ponents of good, healthy, or praiseivorthy pus — the pus laudabile of the Older 
authors — literally, the pus to be commended, as showing a benign form of in- 
flammation, indicating that the process, though a morbid one — a disease — is 
going on regularly, and promises a fortunate issue (Watson). It is the lauda- 
ble pus of surgical writers. When, however, the process deviates from the 
state of health — deviatas from the usual and regular course of the morbid 
action in a person otherwise healthy — then we find not only variations in the 
pus-cells, but multiform mixtures of withered cells appear, with molecular and 
fatty matter, escaped and shrivelled nuclei, blood-corpuscles, and fragments 
of granular matter like shreds of fibrin. The liquor puris becomes unduly 
liquid, and the pus is then said to be watery or ichorous. It may even, in weak 
and tuberculous patients, consist chiefly of a thin serum, mixed with flakes or 
curdled, when it has been called serous pus. When the coloring matter of 
blood is mixed with it, it is called sanious pus. Chemical or vital changes of 
various kinds bring about a peculiar decomposition in pus while yet in contact 
with living parts, although it is probable that atmospheric air, or gases from 
an internal cavity, may have to do with the change ; but hydrosulphate of 
. ammonia is frequently developed, especially in abscesses about the alimentary 
canal, near the tonsils or the rectum. The stench is then most offensive when 
the fluid is set free. Pus, besides possessing certain chemical properties, may 
possess certain specific properties : thus, it may be impregnated with certain 
poisons, as that of syphilis, or of small-pox ; it is also often, in certain consti- 
tutional states, loaded with foreign matters, such as urate of soda. 

The formation of pus is termed suppuration. It takes place under three 
conditions, namely, — (1.) Circumscribed ; (2.) Diffused ; and, (3.) Superficial. 

As examples of the circumscribed formation of pus, may be mentioned an 
abscess, a boil, or phlegmon, in which the suppuration is inclosed within a 
cavity whose walls are composed of connective areolar tissue, and into which 
interstitial exudation of inflammatory lymph and serum has extended over a 
certain area. It happens that while the central portion of an area has become 
purulent {i. e., has produced pus-cells as a result of the continuous premature 
proliferation of tissue), the peripheral part has maintained its firmness and 
solidity by activity of nuclear growth ; and sometimes a " thin, opaque, yellow- 
ish-white layer, easily detached," separates the suppuration area from the 
denser part. This has been called a "■pyogenic memhrane," from the supposi- 
tion that its function is to secrete the pus, whereas the nuclei and cells of the 
denser part are growing by continuous but premature development into pus- 
cells. Abscesses are sometimes formed without any of the usual accompany- 
ing signs of inflammation being present. They are generally slowly formed, 
and are named old or chronic abscesses. When suppuration happens in the 
natural cavities of the body, it is still circumscribed by the cavity. It is not 
then, however, called an abscess, but a purulent effusion into the cavity. 

Diffuse suppuration is exemplified in phlegmonous erysipelas, or the purulent 
infiltration of an organ. ■ In such cases the inflammation extends through a 
wide extent of tissue, and from first to last the boundaries are ill-defined. 
The growth of pus-cells is distinctly interstitial. They are generally rapidly 
formed, and the tissue becomes thoroughly infiltrated, as if soaked in pus. 
The usual want of cohesion in the elements of tissue involved in inflammation 
prevails from the first, and ultimately large sloughs, or death of portions of 



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96 TOPICS KELATIVE TO PATHOLOGY. 

texture, may take place. In some textures of a loose kind it is believed that 
the pus may spread about or infiltrate parts by its own gravity, thereby lead- 
ing to secondary destruction of tissue and the formation of what are called 
sinuses. 

The incipient progress of diffuse suppuration is probably not dissimilar to 
that of a phlegmonous abscess, but the inflammation is generally of a different 
type, and all the processes are less complete ; thus, no fibrinous lymph circum- 
scribes the limits of the abscess, nor does any membrane form to limit the pus. 
The process of suppuration is less perfect, so that the abscess often contains 
shreds, or even large portions of mortified and loose connective tissue. The 
pus is less healthy, is thinner, containing a larger portion of serum, and often- 
times portions of loose fibrinous lymph.- The pointing of this form of abscess 
differs also from that of the phlegmonous abscess, for the pus readily passes 
from its original seat, by infiltration, and gravitating towards the most depend- 
ing position, presents a soft, broad surface, without any indications oi pointing. 
Such collections of matter are always of greater extent than phlegmonous 
abscesses, for the free transmission of pus from part to part occasions a great 
extension of the original disease. When these diffused abscesses open, the 
phenomena which result depend very much on the nature of the opening, and 
how it has been effected. "I have seen," says Mr. Hunter, "large lumbar 
abscesses open of themselves on the lower part of the loins, which hav.e dis- 
charged a large quantity of matter, then close up, then open anew, and so go 
on for months, without giving rise to' any disturbance ; but when opened, so 
as to give a free discharge to the matter, inflammation has immediately suc- 
ceeded, fever has come on, and, from the situation of the inflamed part, as 
well as from the extent of the lesion, death in a very few days has been the 
consequence." The same result has also occuri'ed from liberating collections 
of the diffuse suppurative process in other parts. In erysipelas, however, 
which so often gives rise to this form of abscess, a free opening is often neces- 
sary, to allow of the escape of the portions of loose areolar tissue they contain. 

Superficial suppuration may be observed in gonorrhoea, purulent ophthalmia, 
and generally in inflammation of mucous and cutaneous surfaces. There the 
growth of pus can be clearly traced where stratified, as well as columnar, 
epithelium naturally exists. Upon the skin the development of pus may be 
seen to proceed from the rete Malpighii, as a growth by continuous premature 
development of cells from this part of the young cuticle. In proportion as 
these young cells give birth to younger germs (proliferate), a separation of 
the harder layer of epidermis ensues, and a vesicle or pustule is the result. 
The exact spot where the growth of pus occurs corresponds to what would be 
the superficial layer of the rete Malpighii; and if the membrane of the vesicle 
be stripped off, the cells of the rete, in process of conversion into pus, in place 
of epithelium, will adhere to the epidermis, and be stripped off with it (ViK- 
CHOw). In the deeper layers the cell-elements, which originally, have only 
single nuclei (centres of nutrition, growing or germinal centres), divide, so 
that their nuclei (or centres of growth) become more abundant. Single cells 
have their places taken by several, which in their turn again provide them- 
selves with dividing nuclei, and so the process of multiplication goes on. 

Dr. D. R. Haldane, of Edinburgh, has observed and recorded the contin- 
uous development of pus-cells from the cylindrical variety of epithelium. In 
a case of small-pox he found the larynx and trachea coated over with a soft, 
dirty-looking deposit, which was found to consist of pus-cells. On gently 
scraping the surface, the cells were found enlarged, and, in place of contain- 
ing a single nucleus, each contained several — three, four, or more. These 
were derived from the proliferation of the original nucleus. External to the 
cells were young ones in all stages of development (Edinburgh Medical Journal, 
Nov., 1862, p. 439). ^ v y 

The more completely the epithelium is of the stratified kind, the less is the 



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GROWTH OP PUS-CELLS. 97 

surface liable to ulceration (e. g., the urethra in gonorrhcea) ; but those mucous 
surfaces where the epithelium is of the cylindrical form scarcely ever produce 
pus without ulceration (e. g., the intestines). Pus-cells, mucous cells, and 
epithelial cells are now regarded pathologically as equivalent elements, which 
may replace one another ; but physiologically they are not equivalent ele- 
ments, inasmuch as they cannot perform each other's functions. Deeply seated 
pus-formation may proceed from connective tissue, or from the nuclei of vessels 
or sheaths of tissue. An enlargement of the connective tissue germs occurs 
(Otto Webee), which divide and subdivide, and so multiply excessively by 
divisions of the larger germinal masses or cells. Round about the irritated 
or inflamed parts, where single cells lay, masses or groups of cells are formed, 
a large new formation grows, and towards the interior of this growth heaps 
of little cells accumulate. These little accumulations occur at first as diffuse 
" infiltrations" of roundish masses, encircled by an intermediate growth, which 
continually liquefies as proliferation of the cells extends. Virchow regards 
this liquefaction as of a chemical nature ; the intermediate substance (which 
yields gelatine), becomes transformed into mucus, and being ultimately con- 
verted into an albuminous fluid, is thus rendered liquid. Thus two different 
modes of pus-formation are distinguished, according as (1) the growth of the 
pus-cells proceeds from the germs of superficial tissue, like epithelium, or (2) 
from connective tissue ; and two forms of inflammation can in like manner be 
separated from each other, namely : (1.) The parenchymatous inflammation 
(p. 78, ante), where the process runs its course in the interior of the tissue- 
elements (e. g., connective tissue cells or germ masses, hepatic cells), without 
our being able to detect the presence of any free fluid which has escaped 
from the blood, but where softening and fluidity are due to the process above 
described. (2.) The secretory (exudative) inflammation of superficial tissue- 
elements, where an increased escape of fluid takes place from the blood, and 
conveys the new products of growth and altered secretion along with it to the 
surface. 

The parenchymatous inflammation has from its outset a tendency to alter the 
elements of tissue and their special functions. Whereas the secretory inflam- 
mation, with a free exudation, in general affords a certain degree of relief to 
the part. Witness the relief which follows the free flow of mucus in catarrh. 
It conveys away a great mass of noxious matter, and the part appears to 
suffer much less than a part which is the seat of a purely parenchymatous in- 
flammation. In gonorrhoea, also, we have an example of how the pus result- 
ing from the secretory form of inflammation is carried away by that trans- 
udation of fluid (exudation) which removes the pus-cells from the surface, 
without the slightest appearance of ulceration (Viechow). 

The description here given regarding the formation of pus is based on the 
great fact, demonstrated originally by Goodsir, that all new cells proceed 
from " centres of nutrition," from other cells, or from the nuclei of them ; 
and, as Dr. Haldane justly observes, "We must not expect to be able, in the 
case of every abscess or purulent discharge, to trace thus distinctly (as has 
been done in the preceding paragraphs) the origin of the pus-cells. There is 
only a certain stage in pathological as in physiological growth in which the 
actual mode of development can be followed. We might as well expect to 
be able to discover, by an examination of the mature fcetus, the different steps 
by which its organs had been formed, as to be able, in a ripe abscess, to deter- 
mine in what way normal had been converted into abnormal tissues." 

There are especially three events which, with more or less frequency, accom- 
pany or follow inflammation in a part. These are softening, ulceration, and 
mortifliCation. 

Softening, or diminished cohesion of tissue, is an almost constant result. 
It may be due not merely to mechanical separation by infiltration of the 
component elements of tissue, but to a loss of the vital cohesive properties, 

VOL. I. 7 

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98 TOPICS RELATIVE TO PATHOLOGY. 

and impaired function of the tissues themselves, which tend towards their 
liquefaction and degeneration. Examples of this may be seen in the inflam- 
mation upon mucous surfaces already referred to, also in the inflammatory 
red softening of the brain and spinal cord, and in the lungs, where a peculiar 
brittleness and rottenness is imparted to their flbrous substance or skeleton 
texture. Such softening is due to vital changes in the proper tissue, often 
independent of any interstitial infiltration. The most remarkable example 
of inflammatory softening is that which occurs in bones. An acutely inflamed 
bone is so soft that it may be cut with a knife (Stanley, Paget). 

But while some parts are softened, others are removed altogether by the 
process of interstitial absorption, as it has been termed. This phenomenon is 
best seen in bones which have been inflamed. Such absorption gradually 
precedes the extension of the inflammatory process, and leads, in the case of 
abscesses, to their spontaneous evacuation, commonly called the "pointing of 
an abscess." The inflammation continues, and the growth of pus moves along 
in a definite direction, towards the cutaneous or mucous surfaces of the body 
in its vicinity ; but as the integuments are generally the more prone to inflam- 
mation, it is probable that they thus become soft, and yield sooner than the 
mupous surfaces do. 

Hectic Fever.^ — If suppuration continues beyond the powers of the consti- 
tution to supply the process with material to form inflammatory lymph and 
pus — if the inflammation continues, and becomes chronic as to time, inflam- 
matory lymph continuing to be exuded, and pus continuing to form in profiise 
quantity, especially if an internal organ is its site — a characteristic type of 
febrile symptoms is apt to supervene, constituting hectic fever. 

It is not to be supposed, however, as was once believed and taught, that 
hectic fever is due in every case, to the continued formation of pus. There are 
forms of hectic fever unconnected with suppuration anywhere, but associated 
with some analogous wasting of the bodily substance ; for example, a pro- 
longed secretion of milk in mothers who suckle their infants beyond the natural 
period. In all cases where a drain upon the system is established beyond its 
means, such a complex morbid condition of the body as hectic fever may be 
thus induced, and the mischief may not be revealed by any other symptoms. 

This type of fever is particularly distinguished from the inflammatory and 
typhoid forms of fever (described at pp. 88 and 90), by its remarkable inter- 
missions, which are usually periodical ; a period of remission and a period of 
exacerbation occurring once, and sometimes twice, in the twenty-four hours. 
It is also characterized by an excessive waste of the tissues of the body ; and 
the sweating which attends the paroxysms causes great exhaustion. The 
assimilative and nervous functions are comparatively unimpaired, so that it is 
a febrile condition generally of very long continuance. The mind remains 
perfectly clear — often vigorous and active — even when the body is debilitated ; 
and if the intervals between the paroxysms are tolerably free from febrile ex- 
citements, the hectic type of fever may be protracted much beyond what at first 
sight might appear credible. Thus it is sometimes within our power to alle- 
viate greatly this condition. If, however, the fever does not abate during the 
remissions of the excessive paroxysms, when sweating continues profuse, and 
when suppuration or other wasting discharge is excessive, the fatal termina- 
tion approaches rapidly. 

The leading symptoms of this form of fever have been watched and de- 
scribed minutely by many observers, non-professional as well as professional. 
The fever creeps on insidiously, and almost imperceptibly ; and the physician 
is at first led to suspect its existence only by a very slightly increased fre- 
quency of pulse, and a small degree of heat of skin, occurring generally towards 
evening, and subsiding before the beginning of the next day. The pulse is 
subject to temporary quick excitement from slight causes, such as by exertion, 
by emotion, or by food, as after meals. The heat is especially felt in the palms 

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THE HECTIC TYPE OF FEVER. 99 

of the hands and soles of the feet. The excitement of the pulse gradually 
begins to be more and more easily induced throughout the day, daily loses in 
power and increases in frequency ; and towards evening the general exacer- 
bation of the febrile state becomes regular, and is unmistakable. Periodic 
exacerbations or febrile paroxysms occur almost invariably towards evening, 
and remissions now become distinctly marked. The exacerbation reaches its 
height about midnight, and terminates by a profuse perspiration or sweating 
stage towards the morning. This sweating is sometimes called colliquative, 
and may be replaced or accompanied by diarrhoea. Occasionally a second 
paroxysm occurs in the morning after breakfast (Wood), or at noon, as de- 
scribed by Cullen ; and as a midday meal was common in his day, it is prob- 
able that these slighter paroxysms may be attributed to such causes as the 
simple taking of food. Generally, however, in the earlier periods of this type 
of fever, the interval from morning till towards the afternoon and evening is 
free from fever ; but in the advanced stage the fever becomes nearly constant, 
while the evening exacerbations and the morning sweats remain character- 
istic to the end. The following diagran shows records of temperature in a 
case of suppuration of knee-joint and abscesses in kidney, described by Mr. 
John Croft (Holmes's System of Surgery, vol. i, p. 288). The pulse of.the 
hectic patient is scarcely ever so hard and full as the pulse in inflammatory 
fever; nor is it so soft and compressible as the pulse of the typhoid patient. 
It expresses a middle condition between the two, of very variable character, 
both as to quickness and strength, according to the degree of exhaustion of 
the patient and the amount of febrile reaction. Often during the paroxysm, 
or during temporary excitement from slight causes, it reaches 120 beats in the 
minute, the beat being performed with a jerk, as if the result of irritation upon 
a weakened heart (Wood). 

The heat of skin during the paroxysm is often considerable, and always 
distressing, so that little more than the slightest covering can be endured. 
The respirations are quick and short. The appearance of the face is so char- 
acteristic by its florid circumscribed suffusion, that this hectic fliish of the 
cheek, limited to a spot in its centre, is now well known. The delicate 
bright-red color and circumscribed form of the flushed spot contrast strongly 
and often beautifully with the pale cheek, and the bright and sparkling eye, 
with its sclerotic of pearly whiteness. The surface of the skin is harsh and 
dry, and towards the close of life the region of the ankles is apt to become 
oedematous. The patient loses flesh rapidly, and as death approaches he 
becomes exceedingly emaciated. It is then that diarrhoea is apt to super- 
vene, and to aggravate the sweating, so as completely to exhaust the remain- 
ing strength. The mind, unclouded before, gently wanders now, and the 
ftmctions of life cease, generally without a struggle. It is often one of the 
closing symptoms, most strongly marked, in pulmonary consumption; and 
the non-professional pen of the great novelist, Charles Dickens, has beauti- 
fully portrayed its more striking features in the death of Smike : 

" But there were times, and often too, when the sunken eye was too bright, 
the hollow cheek too flushed, the breath too thick and heavy in its. course, the 
frame too feeble and exhausted, to escape their regard and notice. There is 
a dread disease which so prepares its victims, as it were, for death ; which so 
refines it of its grosser aspect, and throws around familiar looks unearthly 
indications of the coming change, — a dread disease, in which the struggle 
between soul and body is so gradual, quiet, and solemn, and the result so 
sure, that day by day and grain by grain the mortal part wastes and withers 
away, so that the spirit grows light and sanguine with its lightening_ load ; 
and feeling immortality at hand, deems it but a new term of mortal life, — a 
disease in which death and life are so strangely blended that death takes the 
glow and hue of life, and life the gaunt and grisly form of death." 

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100 



TOPICS RELATIVE TO PATHOLOGY. 



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CHANGES IN THE ELEMENTS OF LYMPH. 



101 



PLASTIC INFLAMMATION. 



Fig. 4. 



Definition. — A form of inflammation in which the material produced not only 
tends to solidify as fibrin, but is loaded with elementary colorless corpuscles ; and 
is, for the most part, peculiar to serous surfaces, to the mit-surfaces of ivounds, and 
flaps of amputated parts. 

Pathology. — In the early stages of inflammation of a serous membrane, the 
free surface, wliich ought to be smooth and glistening, becomes covered with 
a soft " lymph," capable of being moulded into form, and hence described as 
plastic. It is seen in most characteristic perfection in some forms of peri- 
carditis. On the free surface of any serous membrane so inflamed the epi- 
thelial cells become swollen, opaque, and loosened. They fall off altogether 
into the cavity of the serous sac. A rapid multiplication of their contained 
nuclei ensues, set free by the breaking down of the inclosing cells. 

Productive changes at the same time occur in the corpuscles of the sub- 
epithelial connective tissue, and groups of rudimentary corpuscles appear, by 
germination from the nucleated protoplasm. Continuing the description, the 
best ever given, in the words of Mr. Paget, it is found that, " as the inflam- 
mation advances, these rudimentary cells multiply with great rapidity, so that 
adjacent groups run together and form masses of immature corpuscles, which 
are so numerous in the focus of the inflammation that the part seems to be 
altogether composed of these new productions, and all trace of its natural 
structure is lost. Not unfrequently the more superficial layers of this corpus- 
cular lymph become detached and fall into the liquid exudation, which is 
formed with more or less abun- 
dance into the serous cavity, where 
they may be mingled with the 
fibrinous coagula which usually 
form in that fluid" (iSurgioal 
Pathology, p. 247). It is impos- 
sible, without isolation of the 
cells composing the thick layer 
of corpuscular lymph, to recog- 
nize their forms. Towards the 
free surface the cells are usually 
pale round corpuscles, possessing 
a well-marked nucleus, invested 
by soft, faintly granular proto- 
plasm. Beyond these the nuclei 
tend to subdivide, and the cells 
to elongate into fibre-cells. In 
the subepithelial tissue proliferation in the corpuscles of the connective tissue 
goes on with an activity proportionate to the inflammatory action. _ An en- 
largement first takes place of the single nucleated cells ; then the nuclei divide, 
and for some time multiply excessively. These changes are very soon followed 
by divisions of the cells themselves; so that round about the inflamed part, 
where single cells only were found, pairs, or even multiple groups of cells, are 
subsequently found. This process is name proliferation, and is well shown m 
Fig. 4, from an inflamed pleura, but the appearances are similar from below 
any serous surface; or in connective tissue, as in the flap of an amputated 
limb (ViRCHOW, Paget, Turner). 

In addition to this local multiplication of material derived from the elemen- 
tary structures of the part, it is at present a subject of inquiry ho,w far the 
observations of Cohnheim give grounds for belief that much of the purely cor- 
puscular forms on the free and soft parts of the lymph may not have migrated 
from the bloodvessels. 




From inflamed pleura (after Paset and Tuenek). 



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102 



TOPICS RELATIVE TO PATHOLOGY. 



Examined under the microscope, the lymph of plastic inflammation usually 
possesses two distinct elements — namely, a filamentous basis, composed of 
very delicate threads crossing one another in all directions. Amongst these 
are entangled the cell or corpuscular elements of the lympb. These elements 
are described as plastic-cells, fibre-cells or fibro-cells, caudate or fibro-plastic 
cells ; all of which may become so elongated and condensed as to assume the 
appearance of white fibrous tissue. Figs. 5, 6, and 7, after Bennett, show 
nuclei (Fig. 5) in the fibrinous product developing into fibres; fibro-plastic 
cells (Fig. 6) developing into fibres; and into (Fig. 7) white fibrous tissue. 



Fig 5 



Fig. 6. 



Illill 





Nuclei in the fibrm s prol i t develop- Fibro-plastic cells developing them- Perfect white fibrous 
ingthemsl s into I 1 r s (BL^^El r). selves into fibres (Bennett). tissne (Bennett). 

Eventually this new matter becomes organized ; that is, it becomes supplied 
with blood and bloodvessels, and is vascular in proportion to the amount of 
such supply. New bloodvessels sprout up in loops from the vessels of the 
adjacent texture. When these fibrinous products form on free surfaces like 
the pericardium or peritoneum, or on a mucous surface, as in croup or dysen- 
tery, the film of lymph is usually called a. fake membrane. 



RHEUMATIC INFLAMMATION. 

Latin Eq., Iivflnmmaiio Rheumatica ; French Eq., I. Rheumatique ; German Eq., 
Rheumalische Entzundu->ig ; Italian Eq., Inflammaziane Reumatica. 

Definition. — Inflammation concurrent with an attack of rheumatism; or in a 
person liable to such attacks. 

Pathology.— As the subject of rheumatism will be afterwards fully con- 
sidered, a notice merely of the peculiarities of rheumatic inflammation is all 
that is required here. Certain textures are especially liable to rheumatiq 
inflammation — namely, the fibrous tissues of the joints, aponeuroses of muscles, 
sheaths of tendons, neurilemma, periosteum, muscles, and tendons. The in- 
flammation is attended with great pain (but not so great as in gout), and its 
severity is probably owing to the dense and unyielding nature of the textures 
especially implicated, and which are subjected to stretching and pressure in 
their elements by the dilated capillary vessels and local inflammatory redema. 
Such inflammation is generally held to be rheumatic when these fibrous tissues 
are implicated m an idiopathic way, and independent of any traumatic origin. 
There is also a great tendency for the inflammatory lesion in rheumatism to 
pass from the part first aflfected to others of analogous structure and function. 

In rheumatic inflammation of joints, the synovial capsule of one or more is 
generally the texture most deeply implicated ; but the inflammation seldom 
reaches a great degree. Fluid exudation into the cavity of the joint is not 
apt to be copious, nor fibrinous, nor very purulent. Inflammatory ojdema of 



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PATHOLOGY OF GOUTY AND GONORRHCEAL INFLAMMATION. 103 

the connective tissue round the joint accounts for any visible swelling. A 
predisposition to rheumatic inflammation is certainly inherited, and those who 
have had an attack are very liable to others. Recovery is the usual termi- 
nation, by a gradual and not always regular diminution of symptoms. 



GOUTY INFLAMMATION. 

Latin Eq., Inflammatio Podagra; French Eq., I. GouUeuse; German Eq,, Gicht- 
ische Enizundung ; Italian Eq., Inflammazione Oottosa. 

Definition. — A form of inflammation characterized especially by the intensity 
of pain, by oedema of the part, and desquamation of the cuticle when superficial 
structures are attacked; and occurring in those predisposed to gout. 

'Pathology. — As the nature of gout will be afterwards fully considered, the 
character of the inflammation attending that general disease alone requires a 
short notice here. The pain of the inflammation is very intense, and difiers 
from that produced by injury. The oedema also is peculiar, and may not at 
first be obvious on account of the great tension of parts, when inflammation 
is violent, and the skin is distended and shining. When the inflammation 
begins to subside, pitting is then easily produced, and the presence of fluid 
made evident. In this respect it differs from rheumatic inflammation, in 
which oedema is not local. After complete subsidence of the gouty paroxysm, 
desquamation of the cuticle takes place. It is most usually observed from 
about the feet and hands, and but rarely from the knees; and, according to 
Dr. Garrod, the desquamation seems to bear some relation to the amount of 
the previous oedema, and consequent distension of the skin. Now and then 
the nails have been shed after a severe attack of gout. The presence of much 
excrementitial matter in the blood of gouty people tends to influence the 
products of inflammation ; but it is rare indeed that inflammation in gout is 
followed by suppuration, although, at first sight, when the disease is most 
intense, and the part is swollen, red, hot, and tender, suppuration looks as if 
it were inevitable. 

The cases which come to suppuration are those in which the gouty concre- 
tions (of urate of soda), acting as a foreign body, or local irritant, establish 
suppuration. The inflammation of gout is indeed "characterized by an 
explosive local appearance of uric add; and on consideration of the circum- 
stances under which this explosion occurs, the inference suggests itself, that 
materials transformable into uric add were previously accumulated in the 
texture which inflames" (Simon). 



GONORRHCEAL INFLAMMATION. 

Latin ^q. , Inflammatio Gonorrhoica ; Frknoh Eq.,/. Blennorrhagique ; German Eq., 
Gonurrhoische Entziindung , Tripperariige Entzundung ; Italian Eq., hiflainma- 
zione Blennorragica. 

Definition. — A form of inflammation arising about flve days after the direct 
contagion of gonorrhceal pus within the orifice of the urethra. 

Pathology. — Although the process of inflammation in the mucous mem- 
brane of the urethra, which constitutes a gonorrhoea, is not different from the 
process of inflammation in any other portion of a mucous membrane, and is 
an example of a catarrh, yet as the inflammation is peculiar in being due to 
a specific cause, and gonorrhoea, therefore, is a specific disease, the inflamma- 
tion requires a short notice here. 

The peculiarities of gonorrhoeal inflammation are: 

1. Its cause distinguishes it from all other catarrhs which affect the mucous 

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104 TOPICS RELATIVE TO PATHOLOGY. 

membrane of the urethra or of other regions, and the disease never arises 
otherwise than by contagion. 

2. The nature of the specific poison is as little known as that of small-pox, 
or other communicable poison; it is only certain that it produces a specific 
result, invariably the same, case after case. The viriis is a something fixed 
and specific, conveyed in the secretion of a diseased mucous membrane, by 
contact with which secretion, in those susceptible of infection, a similar com- 
plaint is transmitted from person to person. 

3. Between the period of contagion and the obvious expression of the dis- 
ease, there is a certain interval — three to eight days — known as the period of 
incubation ; earlier or later periods are exceptional. 

4. The susceptibility to gonorrhoeal inflammation varies greatly in difierent 
persons; and the causes of increased or diminished susceptibility are quite 
unknown. • 

5. Certain portions only of mucous membrane seem susceptible of gonor- 
rhceal inflammation. These are,— -the urethra, the female genitals, the con- 
junctiva, and the rectum ; all other parts of the mucous membrane remain 
incapable of undergoing the specific infiammation of gonorrhoea. Diflferent 
portions of the urethra also are more susceptible to the influence of the poison 

'than others; and although the infecting secretion acts first upon the orifice of 
the urethra, the chief site of the gonorrhoeal infiammation is in the fossa navie- 
ularis. During the first and second, week of the disease, the anatomical 
changes are entirely confined to this portion of the urethra, a portion which 
is very vascular, and very richly furnished with glands. Many complica- 
tions may be associated with gonorrhoeal inflammation, all of which will be 
fully noticed when the disease is treated of in a subsequent part of this work. 



GANGRENE. 

Latin Eq., Gangrcena ; French Eq., Gangrine; German "Kq,., Brand — Syn., Gan- 
gran ; Italian Eq., Gangrena. 

Befinition. — Incomplete mortification, or death of a portion of a soft organ or 
tissue, while the rest remains alive. 

Pathology. — When complete death of the part is accomplished, the condi- 
tion is termed sphacelus. In the hard parts, as in bones, a somewhat similar 
distinction obtains in using the terms caries and necrosis. Necrcemia means a 
corresponding death of the blood. Particular names are also given to the 
dead parts. A dead piece of tissue is called a slough. A dead piece of bone 
is called a sequestrum. Progressive gangrene of soft parts is usually called 
sloughing. 

Mortification of the soft parts may be white or black in appearance, humid 
or dry. The mortified part has a black aspect when the blood is extravasated 
through the walls of the bloodvessels into the afiected tissues, giving to the 
part a purple or dingy hue, while to the touch it is soft, inelastic, and doughy. 
It may appear white, when, by the action of cold, the blood has been driven 
from the part before its death commences, which subsequently freezes per- 
fectly white. 

Humid mortification occurs when the blood transudes in a fluid state, and 
after its exudation separates into its constituent parts, so that the serum, set 
free, dissolves in it the red globules, raises up the cuticle in bladders, and 
forms what are termed " phlyctence." Air, generated by a process of com- 
mencing putrefaction, is not unfrequently contained in the phlyctence, and 
gives, to the finger touching the part, a sensation of crepitation. 

Dry mortification is rare, and has sometimes been caused by the ergot of 
rye, or other diseased grain, used as food, giving rise to the condition known 

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PATHOLOGY OF PASSIVE CONGESTION. 105 

as ergotism. In the year 1716, dry mortification appears to have been to a 
certain extent epidemic at Orleans, fifty cases having been treated at the 
H6tel Dieu of that city. Dodard described it as beginning generally in one 
or both feet, with pain, redness, and a sensation of heat or burning like that 
produced by fire. At the end of some days the part became cold, as black as 
charcoal, and as dry as if it had been passed through fire. Sometimes a line 
of separation was formed between the dead and the living parts, and the com- 
plete separation of the limb was effected by nature alone. In one case the 
thigh separated in this manner from the body at the hip-joint. In other cases 
amputation was necessary. Mr. Solly has given an interesting case of this 
description, which occurred in the practice of Mr. Bayley, of Odiham. The 
patient was a child three years and seven months old, from whom, by this 
spontaneous process of nature, both arms were removed above the elbow, the 
left leg below the middle of the thigh, and the right foot above the ankle- 
joint, being a remarkable instance, in modern times, of this destructive disease 
(see " Ergotism," and Med.- Chir. Trans., vol. xxii, p.. 23). 

The bones, the brain, the lungs, the liver, the spleen, and the kidney, are 
all liable to sphacelus and gangrene; so are the different tissues, as the areolar, 
cutaneous, nervous, and serous. The muscles, tendons, aponeuroses, and blood- 
vessels, are likewise all liable, but in a less degree. 

It is necessary to distinguish the incomplete death of soft parts, or gangrene, 
from the condition afterwards to ' be described as degeneration ; and which 
sometimes precedes complete death of the degenerate part. 

The degeneration of a part is to be distinguished from gangrene, or actual 
death, by this, — " that the degenerate part never becomes putrid ; and that 
no process ensues for its separation or isolation, such as we can see in the 
case of a dead part" (Paget). A tissue, however degenerate, remains in con- 
tinuity with the parts around it, or is absorbed. If the tissue were dead, the 
parts surrounding it would separate from it, and the dead portion would be 
ejected from them. 

But there are also some conditions of parts where it is impossible to say 
whether they are dead or alive ; a condition which may be termed "suspended 
animation." Thus, the end of a finger, in a case of diseased heart, may be 
cold, livid, insensible, and shrunken for three days ; or the foot of an old man 
cold, livid, purple, mottled, and numb for a whole week; and during these 
times it could not be told whether the parts were alive or dead. But, as both 
parts afterwards regained all the signs of life within the days mentioned by 
Mr. Paget, time alone showed that both parts had been in a state of " sus- 
pended animation." In the same way parts that are frozen, as by the mode 
of inducing local anaesthesia by the ether-spray, introduced by Dr. Richard- 
son, or parts that are crushed or otherwise severely injured, have their "ani- 
mation" or vitality "suspended" for a time. 



PASSIVE CONGESTION. 

Latin Eq., Congeslio Prtssivn; French Eq., Congestion Passive; German Eq., Passive 
Congestion; Italian Eq., Covgesiione Passiva. 



Definition. — Overfulness of blood in the capillary vessels of apart; as 
with impairment of the vital relations between the blood and minute elements of 
the texture, as the cause of the sluggish flow of the blood in, the capillaries. 

Pathology. — The term congestion, or hypercemia — meaning, literally, a mere 
excess of blood in a part, or over-bloodedness— has always been regarded as of 
two kinds, namely, active and passive. The former, or active congestion, cannot 
be separated from inflammation of a texture, of which it forms a stage or part 
of the morbid process, as already described, and, in fact, leads up to it; while 

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106 TOPICS RELATIVE TO PATHOLOGY. 

the latter, or passive congestion, merely predisposes to inflammation from trifling 
injuries, obstructs recovery, tending to molecular degeneration of tissue, and 
to atrophy ; and, farther, it leads to dropsy. 

Much confusion exists as to the use and interpretation of the term conges- 
tion; and as no one has put the subject in a clearer light than Professor 
Eokitansky, and also Dr. Moxon, in his very interesting Lectures, at Guy's 
Hospital, on Analytical Pathology, the account here given is based mainly 
on his exposition, in Med. Times and Gazette, July 16, 1870, and that of 
Eokitansky, in vol. i, p. 107. 

The relations between active and passive congestion have been described as 
simply, that, too much blood being brought into a part, active congestion, or 
hyperemia, is established; on the other hand, when too little blood passes out 
of a part in proportion to what passes into it, the state of passive congestion 
is established. But, in the first case, the description falls short of the truth, 
inasmuch as too much blood passes out of the part as well as into it ; and the 
congestion is not only active, as regards the flow of blood to the part, but also 
as regards its flow out of it. In the second case, the description oi passive con- 
gestion involves two forms of congestion, difiering in their causes, and also in 
their results. The; causes of one form are purely mechanical, the causes of the 
second are truly passive. 

Examples of purely mechanical congestion are to be studied in the following 
morbid conditions : Narrowing of the mitral orifice of the heart, by the mechan- 
ical stoppage of the blood at the obstructed valve, inducing a very intense 
congestion of the lung. Condensation of the tissue of the lung is the conse- 
quence of the persistence of the mechanical obstruction ; and, at last, some of 
the minute vessels of the lung tissue may burst, causing pulmonary apoplexy. 

The results of congestion due to mechanical obstruction of the venous cur- 
rent are, — 

(a.) Distension of the veins behind the obstruction, leading to stretching 
and straining of their walls, and so, apparently, to leakaga of serum through 
the distended veins into the tissue, producing cedema in connective tissue, or 
dropsy into serous cavities. Habitual use of a tight garter will occasion such 
results of mechanical congestion of the leg ; so will a tumor in the popliteal 
space or -the groin, or habitual distension of the lower bowel by feculent 
matter. 

(b.) Effusion of blood, either from rupture of overdistended vessels behind 
the obstruction ; or, reasoning from the observations of Addison, Waller, 
Cohnheim, and others, who contend that the blood-corpuscles find their way 
through the tissue of capillary vessels without any rupture of them, those cases 
are capable of ex;planation where a free and fatal hemorrhage may come from 
the stomachal mucous membrane, without any trace of a ruptured vessel or 
solution of continuity of the mucous surface. 

Examples of effusions of blood from vessels behind the mechanical obstruc- 
tion are to be seen in pulmonary apoplexy, in the free escape of blood into the 
stomach in cases of cirrhosis of the liver obstructing the portal vein, or in cases 
of obstructive heart disease, in the cerebral hemorrhage that results from infan- 
tile convulsions, and in hemorrhage from varicose veins. 

(c.) A thrombm or coagulum of blood may form during life in the obstruct- 
ed vein. Such clots or thrombi are to be found in the portal veins in cases 
of cirrhosis of the liver ; and in the veins of the bend of the thigh, and pros- 
tatic plexus, in cases of cardiac dropsy. These clots begin to form behind 
the valves of the mechanically distended veins, in the stagnant eddies of blood 
which occupy the hollows behind the valves. Portions of clots so formed in 
these veins may break away and pass into the current of the circulation, and 
passing up the veins through the right side'of the heart, may lodge in the pul- 
monary artery, and cause either sudden death or pulmonary apoplexy. This 
is one form of thrombosis ; and the primary formation of the clot in this 

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RESULTS OF MECHANICAL CONGESTION. 107 

form is to be distinguished from formation of the clot in veins during life, 
which is due to inflammation of the vein, or close to its wall. Such inflam- 
matory coagula constitute another form of thrombosis. They form wherever 
veins are subjected to irritation, such as in cerebral sinuses, in cases of trau- 
matic or other inflammation of the cranium, the veins of unhealthy stumps 
after amputation, such clots being sometimes mixed with true pus ; and when 
such clots pass into the lung, inflammation of the part of the lung supplied 
by the artery is the result. 

(d.) Gangrene may be a result of mechanical congestion, as in the limbs and 
scrotum, from obstructive disease of the heart, or the too tight bandaging of 
a limb may lead to gangrene of finger or toe. 

These four results of congestion succeed each other . as the results of suc- 
cessive increments of mechanical force, and are the natural consequences of 
such mechanical obstruction. 

Passive congestion difiers from this mechanical congestion both in its cause 
and in its seat. Severe emphysema of the lungs and chronic bronchitis fur- 
nish examples of passive congestion of different parts of the body. In emphy- 
sema there is a general lividity of the surface — so constant that it constitutes a 
valuable sign in diagnosis between emphysema and heart-disease, especially 
when the presence of a tricuspid murmur in emphysema, or bronchitis in 
mitral disease, makes the one very like the other. In the case of mitral 
disease, there is free entry of plenty of air into the lungs, but there is little 
blood passing through them. The flow through the mitral orifice is a small 
stream ; but it is well aerated blood, and as such freely passes through the 
capillary vessels and into the veins, where it begins to meet the first mechan- 
ical impediment to its farther progress, and is detained in the veins, then in 
the right heart, and then in the lungs. These being the parts congested, and 
not the systemic capillary vessels, lividity is generally absent in mitral dis- 
ease. On the other hand, in emphysema of the lungs, the hlood circulates 
freely through the lungs; but not so the air. It is with difiiculty, and 
in an imperfect way, that air is renewed in the lungs. The blood, therefore, 
is insufficiently aerated, and so passes to the systemic capillaries in an impure 
state, where a true passive congestion is the result. The normal vital relations 
between the impure blood and the minute elements of tissue are impaired, by 
the unfitness of the blood to nourish the textures. Hence the skin becomes 
livid, as the capillaries are gorged with a slowly moving purple current of 
blood. 

Thus the seat and the cause of true passive congestion are different from the 
seat and cause of mechanical congestion. The seat of passive congestion is the 
capillaries of the part, and is largely due to deficient activity in the vital in- 
terchanges between blood and texture of the part. In mechanical obstruc- 
tion, the seat of the congestion is in the veins, and the cause is not vital, but 
mechanical. 

The two forms may be combined in cases of general languid action of the 
heart, where imperfect circulating force is at the same time a mechanical 
obstacle to the current of blood, and congestion is at the same time both pas- 
sive and mechanical. 

Other examples of passive congestion are seen in the blueness of cold hands, 
redness of the extremities, ears, and noses of people with languid, weakly, or 
feeble circulation ; in the prolonged redness or lividity of fauces following 
severe tonsillitis ; hypostatic hyperaemia of the dependent parts of the lungs in 
fever, where the air fails to pass into the air-vesicles during the imperfect 
respiration. In all these cases the congestion is passive, and secondary to 
local inactivity in the vital changes between the tissue-elements and the 
blood. Eokitansky believes passive congestion to depend upon direct palsy 
of the nervi vasorum, wherewith is commonly associated a depressed energy in 
the remainder of the nervous system. Such palsy may originate in the nerve- 

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108 TOPICS RELATIVE TO PATHOLOGY, 

centres, or it may be peripheral, and is often determined by a morbid condi- 
tion of the blood, especially by its decomposition. The passive congestion of 
asthenic inflammation in organs exhausted by excess of functional activity, 
enfeebled by active congestion, or paralyzed-^o also hypostatic hypersemia 
of the lungs, abdominal and pelvic organs, and the common integuments of 
dependent parts, developed under diminished impulse from the heart— are 
examples of such paralysis, causing congestion. 

The direct results of such passive congestion are, that the tissue becomes 
depraved, becoming atrophied, with more or less molecular change of a de- 
generative kind, and such texture is thereby greatly predisposed to fall readily 
into inflammation under trifling injuries, when the passive congestion will be 
replaced by the active congestion of inflammation, and the power to recover 
from such lesions is very greatly reduced. . . , t • i 

The redness of passive congestion is always of a dark or livid hue. Little 
or no heat is felt in the part ; a sense of weight or dulness is experienced 
rather than pain ; and there is neither obvious tension, induration, nor in- 
creased proliferation in the part. 

The causes of passive congestion may be thus shortly stated, as — (1.) Pre- 
vious perverted vascular function, such that vital interchange between the 
textures and the blood is diminished. It may thus come to be a result of 
previous inflammation or active congestion: Thus local debility of a part 
from any cause favors the depression of textural vital function, and therefore 
to passive congestion. (2.) Diminution of the normal proportion of fibrin in 
the blood renders its fluid portion more transudable, and so favors passive con- 
gestion in dependent parts, as in the lungs in fever. (3.) General debility is 
favorable to passive congestion. 



EXTRAVASATION OF BLOOD — HEMORRHAGE. 

Latin Eq., Srr_^z<sto Sanguinis, Haemorrhagia; Fkench Eq., Exirnvasaiion de Sang; 
German Eq,., BLutextrarasation, JScemorrhagie ; Italian Eq., Stravoso di Sangue, 
Emo'rragia. 

Definition. — Any discharge, transudation, or effusion of blood in its entirety 
from the bloodvessels along which it ought to flow. 

Pathology. — Hemorrhage may be spontaneous or traumatic. The first kind 
of hemorrhage concerns the physician, the second concerns the surgeon. 
Blood escapes from the containing vessels amongst the interstitial elements of 
an organ or tissue, either by rupture of a bloodvessel, by solution of its con- 
tinuity from disease, such as an ulcer, an abscess, or from injury. As a rule, 
there is effusion, hemorrhage, or extravasation of all the blood-constituents; 
except, perhaps, in those cases of transudation or sweating through the capil- 
laries, as the old term " exhalation" was meant to express, and which may 
now be explained by the experiments of Cohnheim, Bastian, and others. 
Virchow's description of a capillary being as homogeneous as a layer of collo- 
dion, abundantly testifies to its capacity for " exhalation" in the sense of 
Cohnheim's experiments. 

These recent experiments, reviving those of Waller and Addison, point to 
hemorrhages from the capillary vessels of a part taking place without any 
rupture of vessel or visible breach of surface. Such hemorrhages, where no 
breach of surface could be found, were wont to be described as hemorrliages 
by exhalation, and were believed to occur in ninety-nine cases out of a hun- 
dred. 

Congestions due to mechanical stoppage of the various currents are amongst 
the most frequent causes of hemorrhage, probably from rupture of overdis- 
tended vessels ; and when the hemorrhage takes place into the substance of 

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CAUSES OF PASSIVE HEMORRHAGE. 109 

any organ, or into any texture interstitial to its elements, the lesion receives 
the name of apoplea^y. 

But there are also hemorrhages from free mucous sur^aees under various 
morbid conditions. For example, the free escape of blood into the stomach 
in cases of cirrhosis of the liver obstructing the portal vein, or in cases of 
obstructive heart disease, are hemorrhages from rupture of vessels behind 
mechanical obstructions. Also cerebral hemorrhages (or apoplexy) sometimes 
result from infantile convulsions, and are due to rupture of vessels from ob- 
struction ; and so are hemorrhages from varicose veins. These are all exam- 
ples of hemorrhage from mechanical obstacles to the circulation. Valvular 
disease of the heart ; hypertrophy of the left ventricle of the heart, with 
capillary impediments to the passage of blood ; affections of the liver, like cir- 
rhosis, which obstruct the flow of blood through the portal vessels, producing 
congestion of the whole portal system, cause hemorrhage in the stomach and 
bowels. " Time was," says Dr. Moxon, " when we could speak strongly con- 
cerning these hemorrhages. Thus, the notion of blood passing through the 
walls of a vessel without a lesion of the latter, is one that could only belong 
to times when the structure of minute vessels was unknown. Capillaries 
naturally possess delicate but perfectly solid and continuous walls ; and it is 
just as possible for a single blood-corpuscle to get through that wall without 
a hole being made for it, as it would be impossible for the entire man to sink 
through the floor of ka apartment without an aperture of his own size existing 
for his passage. But all this is changed now. If the femoral vein of a frog 
be tied or pinched in forceps, and the capillaries of the foot well watched, 
corpuscles of blood are seen to make their way through the capillary walls. 
They evidently go through holes much smaller than themselves, so that in the 
middle of their passage they are hour-glass-shaped, half in and half out of the 
vessel, constricted much where actually passing. Whether the walls of the 
capillaries are composed of cells, adapted to each other so as to leave pores 
between them ; or whether, rather, our minute tissues, during their life, pos- 
sess some of that yielding and closing capacity that one sees in the amoeba, 
which can take in a fellow-creature of its own size through its skin, and then 
close over it, so that there is no remaining opening, — I think we don't know.' 
" It is, indeed, very surprising to find a very free and even a fatal hemorrhage 
from the stomach while the mucous membrane from which the blood must 
have come is entire ; yet no doubt this sometimes occurs. Nevertheless, its 
occurrence must not be accepted without very carefiil search over the mucous 
surface, for the opening of a vessel must be very small." Dr. Moxon instances 
a case where cirrhosis of the liver led to total obstruction of the portal vein, 
by ante-mortem coagulation in it ; and in consequence of this obstruction, a 
varicose oesophageal vein ruptured close to the cardiac orifice of the stomach. 
A small hole was found leading into the vein channel, from which the patient 
had bled to death. The occurrence was ecjuivalent to rupture of oesophageal 
piles, and is an interesting link, connecting common small hemorrhoids, that 
arise from hepatic obstruction, with the dilated vessels on the cheeks and in 
the mouth — all signs of obstructed hepatic circulation — and which were 
really facial haemorrhoids {Med. Times and Gazette, July 16, 1870, p. 58): 

Hemorrhages have also been distinguished into active and passive ; and, 
according to Broussais, all spontaneous hemorrhages are active — i. e., they are 
due to increased action and excess of irritation of the bloodvessels of the 
part. Those, on the other hand, are considered passive which result from 
external lesion of the vessels, as when hemorrhage takes place from a, blow, 
which impairs the vitality of the part and allows the escape of blood into the 
surrounding tissues. Active hemorrhages are typified in the menstrual flow 
of the female, which is natural, and in vicarious hemorrhage and epistaxis, 
common in the young and plethoric. The predisposing causes are,— good 
living, the excessive use of fermented drinks, excessive exercise, as well as a 

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110 TOPICS RELATIVE TO PATHOLOGY. 

too sedentary life. Heaviness and increased pulsation, whicli makes itself 
sensibly felt in the part, commonly precedes tlie flow of blood, owing to the 
local congestion, and also coldness of the feet. The blood evacuated is gen- 
erally of a florid red color. 

There are a number of passive hemorrhages which acknowledge some 
general cause, and which seem to result from some constitutional weakness, 
combined with an altered state of the blood. Protracted disease of kidneys, 
heart, liver, or spleen ; degeneration of vessels, poor diet, or unsuitable food ; 
long watching, excessive evacuations, previous active hemorrrhage in excess, 
scurvy, purpura, are instances of conditions under which such passive hemor- 
rhages are apt to occur. Hemorrhage from the laceration of vessels and parts 
of organs diseased in texture, pulpy and friable, as in laceration of the heart, 
are of this kind. Hemorrhages are also common when the blood contains 
less fibriQ than in health, as in typhus and in scurvy, while they are rare in 
diseases in which the blood contains an excess of fibrin. In hemorrhage 
from plethora, the fibrin remaining the same, or being diminished, the blood 
contains a larger proportion of red globules than in health ; while in scurvy, 
or other depressed states of the system, the fibrin is alone diminished, the red 
globules remaining in normal proportion. In general, in hemorrhage, the 
blood is not buffed, has a large soft clot, and if the hemorrhage has been con- 
siderable, with difficulty coagulates, showing a diminished quantity of fibrin. 
Many substances also which directly contaminate the blood seem to have the 
power of inducing hemorrhage. A solution of subcarbonate of soda injected 
into the veins of animals deprives the blood entirely of the power of coagu- 
lating, and disposes to hemorrhages. Many morbid poisons, also, as that of 
typhus fever and of small-pox, have a similar tendency. Hemorrhage, there- 
fore, may be caused by an altered state of the blood as well as by a diseased 
condition of the tissue, and in many instances, perhaps, is referable to both 
causes. Such passive hemorrhages are not preceded by any signs of local 
congestion or excitement of an active kind. They are usually associated with 
pallor of the countenance, feeble pulse, and a tendency to faintness. 

Plethora and ancemia are thus alike proved to be conducive to hemorrhages. 
In youth, plethora is apt to predominate, and then the seat of hemorrhage is 
generally the mucous Schneiderian membrane, and is named epistaxis. In 
adult age, hemorrhages from the lung and bronchial tubes are called haemop- 
tysis ; from the stomach, hcematemesis ; and from the urinary passages, hcBma- 
turia ; from the uterus, menorrhagia. In old age, apoplexy and hsemorrhoidal 
discharges of blood prevail especially from fifty to the end of life. If such 
hemorrhages are not suddenly fatal, as may be the case with apoplexy, 
repeated hemorrhages from piles, often occurring, tend to embitter existence. 

The effects, and even the appearance of hemorrhages, are generally alarm- 
ing. The effects must be estimated after due consideration of the cause and 
the seat of the hemorrhage. The signs of danger and grounds for anxiety are 
as follows : 

(a.) Depression, restlessness, deep inspirations (expressed by the term 
anxietas), with rapidity of pulse. 
(6.) Pallor of countenance. 
(c.) Loss or imperfection of vision. 

(d.) Syncope, on attempting to sit up. ^ Ease or contentment, with de- 
(e.) Coldness of the extremities. >■ sire to be left alone and un- 

(/.) Wandering or delirium. j disturbed. 

Secondary Hemorrhage. — Effusions of blood are also apt to occur in connec- 
tion with the inflammatory process ; but such hemorrhages are generally from 
rupture of the vessels of the inflammatory products which have recently 
become vascular (Rokitansky). These new vessels are peculiarly delicate, 
and being apt to rend, like the vessels of new granulation, with a very slight 

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CONSTITUTIONAL TENDENCY TO BLEEDING. Ill 

force, especially when they are made turgid or dilated by an attack of inflam- 
mation of the newly-formed material in which they lie, they may be sources 
of considerable bleeding, especially in the stages of congestion and of stasis 
(Paget). Such is probably the explanation of the conversion of a hydrocele 
into a hcematocele ; the inflammatory products of the hydrocele becoming vas- 
cular, and being subjected to slight violence, the new vessels are ruptured, and 
blood pours into the sac. Hemorrhagic pericarditis acknowledges a similar 
mode of causation. To these effusions of blood Mr. Paget gives the name of 
Secondary Hemorrhages. Primary efflisions of blood in inflammation, i. e., 
the effusion of blood direct from the ruptured vessels of inflamed parts, min- 
gling with the inflammatory products, are common in pneumonia, in which the 
extravasated blood gives the sputa their characteristic rusty tinge in that 
disease. In the inflammatory red softening of the brain, the blood is also 
effused direct from the vessels of the inflamed part. 

Other morbid conditions are also liable to hemorrhage ; for example, such 
as are highly vascular, as encephaloid and other cancers, and the highly vas- 
cular walls of cysts. In all these, the hemorrhage is generally capillary. 

Hemorrhag^ic Diathesis — a disposition or liability to habitual hemor- 
rhage — has been described under the names of hceinophilia, hamorrhaphilia, 
hcemorrhophilis, and occurs in some persons as a constitutional peculiarity. 
The tendency is congenital, and is sometimes made manifest immediately 
after birth by the dilEculty with which bleeding from the umbilical cord can 
be subdued, and in some cases death of the infant takes place from such loss 
of blood. In after-life, and shortly after dentition — after the sixth or eighth 
year — the tendency is expressed by the obstinacy of traumatic hemorrhages, 
profuse and dangerous bleeding from very slight wounds, by spontaneous 
bleedings from the gums, nose, bronchi, stomach, intestines, or kidneys ; also, 
as ecchymosis into the texture of the skin and subcutaneous areolar tissue. 
Such spontaneous hemorrhages, however, do not usually occur till after the 
patient has suffered repeatedly from traumatic hemorrhages — the frequent 
loss of blood tending to hypinosis (diminution of fibrin of the blood), and to 
impair its coagulability. Such spontaneous hemorrhages are generally pre- 
ceded by certain phenomena moving or struggling towards the crisis {molim- 
ina) which eventuates in the hemorrhage. Such phenomena constitute the 
" moliw.ina hcemorrhagicicm," and are expressed by cardiac palpitation, tend- 
ency to stupor or indifference, signs of cerebral congestion, pains in the limbs, 
and, in some cases, painful tumefaction of the joints, especially of the wrists, 
knees, and ankle-joints (Niemeyee), with ecchymosis, and fever (Miller),— 
symptoms which continue about a fortnight. . The accidents of a traumatic 
kind which give rise to these alarming hemorrhages are usually extraction of 
a tooth, a leech-bite, biting the tongue, puncture, slight cut, abrasion, or 
laceration, as of the hymen ; and sometimes the slighter the apparent wound,, 
the more obstinate and dangerous is the bleeding from it. The blood oozes 
from the surface, or wells up from the puncture or cut, as if from a sponge, 
or like a continuous spring of water, although no bleeding vessel can be dis- 
covered. No styptic can stanch the flow ; and the bleeding may persist for 
days, and many cases even prove fatal by syncope. At first the blood may 
appear normal, but gradually it grows thin and watery, and coagulates loosely,, 
if at all. The complexion becomes pallid, waxy, and anaemic ; color passing 
from the lips and mucous membrane of the mouth. 

When the bleeding ceases, as it may after a few days, the patient is left in a. 
state of the most extreme exhaustion, .approaching collapse, and recovery is. 
very slow, from the effects of the enormous loss of blood which sometimes 
amounts to many pounds. 

The slightest contusion, bruise, or pressure on the skin of such hemorrhagic 
patients, sometimes leads to extensive extravasations beneath the skin. 

This peculiar state of the system is either congenital or becomes developed 



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112 TOPICS RELATIVE TO PATHOLOGY. 

afterwards as life advances. Those born -with the diathesis have usually in- 
herited the constitution chiefly through the male line. It usually descends 
from a family, one of the members of whom, in previous generations, has 
suffered from the same affection. In its hereditary transmission it furnishes, 
like gout, instances of atavism— i. e., it may in transmission through four gen- 
erations, skip over or miss one, the grandchildren inheriting the disease, but 
not the children. Thus, lost in one generation, the disease reappears inthe 
next. But all cases^are not so inherited, and even when an inheritance, it is 
rare for every member of the family to be affected, the males being more 
liable than the females of the family. 

Many cases die young, and if the tendency is great, the period of childhood 
is rarely survived. On the other hand, eases disclose themselves at a very 
early age, and, abating as age advances, the tendency to bleeding; ceases alto- 
gether, and the patient lives to a good old age. The tendency to bleeding 
also seems to fluctuate; the least abrasion or scratch may at one time threaten 
fatal loss of blood ; at another time bleeding from any similarly slight injury 
will scarcely attract attention. 

Distinct periods of remission and exacerbation are also experienced. The 
"molimina hcBmorrhagicum," already noticed, marks the periods of exacerba- 
tion, which continue about a fortnight. 

The diathesis has points of resemblance on the one hand to scrofula, and 
on the other to scurvy ; but with marks sufficiently characteristic to separate 
it from both. The most prominent are an obviously delicate constitution — ■ 
usually a fair complexion — a thin transparent skin, irritability of the circula- 
tion at all times, occasional attacks of fever. But the cause does not lie in 
the constitution of the textures only, for there is a morbid condition of the 
blood as well as of the bloodvessels. There is a preternaturally delicate and 
vulnerable structure of the coats of the vessels associated with a thin and 
watery condition of the blood. It is deficient in the due proportion of fibrin, 
and in the power of coagulation. Even when wholly at rest, it is incapable of 
forming a dense firm coagulum. An undue tendency to congestion of the capillary 
vessels is a consequence of these changes in the blood and in the vessels ; so 
that when they are cut, not only do they contain too much blood, upon which 
they are unable to contract, remaining open and uncontracted, passively pour- 
ing out their thin contents ; but that blood is deficient in the most important 
of Nature's hemostatics, — the power of coagulation. The minute arterial 
twigs seem to be devoid of any middle substance. They are of a thin feeble 
appearance, and unusually capacious, impaired in contractile power and tone. 
They are friable and easily torn ; hence slight bruises produce serious and ex- 
tensive ecchymosis ; coughing may induce a dangerous haemoptysis, a sneeze 
may bring on uncontrollable epistaxis, and extravasations within internal 
cavities not unfrequently follow a very slight cause. 

But it is necessary in all such cases to find out, if possible, the source of the 
depraved blood and constitutional impairment of texture. Some of the organs 
having to do with nutrition, may be contributing a permanent supply of nox- 
ious material to the system. Hence it is of importance to discover the defi- 
nite tissue or organ from which the derangement in the constitution of the 
blood proceeds. Numerous instances of the hemorrhagic diathesis have 
pointed to a definite organ as its source — namely, either a Vnorbid condition 
of the spleen or the liver ; and in cases of leukaemia, usually towards the close 
of life a genuine hemorrhagic diathesis is developed, and hemorrhages ensue, 
occurring with special frequency in the nasal cavity (as an exhausting epis- 
taxis), and also in or from other parts of the body, as in apoplectic clots in 
the brain, or melsena from the intestinal canal. 

_ The liver, spleen, and lymphatic system of glands require special investiga- 
tion in all cases of hemorrhagic diathesis. 



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FORMS AND EFFECTS OP HEMORRHAGES. 



113 



The following are the special hemorrhages, extravasations of blood, or hem- 
orrhagic lesions, which call for special notice in this text-book ; namely, — • 

1. Cerebral hemorrhage, or the sanguineous form of apoplexy. 

2. Spinal hemorrhage, or spinal apoplexy. 

3. Choroidal hemorrhage, or choroidal apoplexy. 

4. Epistaxk, or hemorrhage from the nose. 

5.. Hcemoptysis (a) from passive congestion; (6) from pulmonary extrava- 
sation, or pulmonary apoplexy. 

6. Hemorrhage into the pericardium. 

7. Hcematemeds, or hemorrhage from the stomach. 

8. Intestinal hemorrhage. 

9. Hsemorrlioids, internal and external.. 

10. Hemorrhage from the rectum. 

11. Hamaturia renalis, or hemorrhage from the kidneys. 

12. Hcematuria vesicalis, or hemorrhage from the bladder. 

13. Hcematocele, or hemorrhage into the tunica vaginalis. 

14. Hemorrhage into ovary. 

15. Peri-uterine, or jielvio hcematocele, or hemorrhage underneath the peri- 

toneum, or within the fold of the broad ligament of the uterus. 

16. Pelvic hcematocele, hemorrhage into the areolar tissue of the pelvis. [15 

and 16 are sometimes described under the name of retro-uterine 
htematocele.] 

17. Uterine hemorrhage, and menorrhagia. 

18. Hemorrhagic cysts. 

Each and all of these forms of hemorrhage will be considered in detail un- 
der the respective organs implicated in the lesion. 

Fig. 9. 





Fig. 8. — Pigment from an apoplectic cicatrix in tlie brain (Vircliow's Archiv., vol. i, pp. 401, 454, plate 
iii, Fig. 7). {a. I Blood-corpuscles which have become granular, and arc in process of decolorizatiun ; (&.) 
Cells from the neuroglia, some of them provided with granular and crystalline pigment; (c.) Pigment- 
granules; (d.) Crystals of htematoidin ; (/.) Obliterated vessel, with its former channel filled with granular 
and crystalline red pigment : 300 diameters ( Virehow, Cellular Pathology, p. 144). 

Fig. 9. — Crystals of hiematoidin in different forms : 300 diameters (1. c, p. 1431. 

There remains now to be noticed the results of blood extravasations. 

The immediate effects of hemorrhage, besides the anremia consequent upon 
great effusion, either out of the body or into its cavities, are lesions of contin- 
uity in textures, impairment or destruction of function, paralysis of the organ 
affected, as in cerebral and muscular hemorrhage. The irritation, too, of the 
extravasated blood, acting as a foreign body, may set up inflammation of sur- 
rounding textures, with eventual organization of the effused products, result- 
ing in a callous condensation of texture surrounding the lesion, and the isola- 
tion, by inclosure of the hemorrhagic clot in a more or less dense capsule. It 
is rare for the hemorrhagic lesion to become purulent. 

A slight hemorrhage is usually cured by absorption of the effused fluid, so 



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114 TOPICS RELATIVE TO PATHOLOGY. 

that the injured and distended textures recover their resiliency. ' The liberated 
red pigment, however, frequently resists absorption, even in slight hemorrhages, 
remaining in a state of minute molecules, scattered over a membrane, or be- 
tween the minute elements of a texture, as a minute or black pigment. Every 
extravasation may also leave behind it a contingent of hsematoidin crystals 
(Fig. 9), which, when once formed, remains in the interior of the organ in 
the shape of compact bodies endowed with the greatest powers of resistance. 
From the numbers of such remains any number of old apoplectic attacks may 
be counted, with remains like Fig. 8. 

Prognosis in cases of hemorrhage is unfavorable under the following condi- 
tions : 

(a.) Into serous cavities, unless limited by other lesions. 

(6.) Into the substances of organs. 

(c.) Under the influence of the hemorrhagic diathesis. 

Treatment. — As.the details for treatment of each of the hemorrhages already 
named will be considered under the account of the respective diseases, there 
only remains to indicate here the treatment suitable for cases of the hemorrhagie 
diathesis, which only finds a place here. 

Nutritious diet, outdoor life, and tonic remedies generally, express the line 
of treatment. 

Medicinal tonics are of first importance, and must be patiently persevered in, 
consistently with the capacity to assimilate food with them. Smart purgative 
doses of sulphate of soda are of benefit in two ways : first, as a purgative and 
hydragogue, diminishing the amount of serum in the blood ; second, as a chemical 
salt, which has the efieet of increasing or promoting the firm coagulation of 
the blood. Acetate of lead and opium also favor coagulation, and tend to calm 
the circulation. They must be administered in Sill and sustained doses. 
Opium seems to have a tonic and astringent efieet on the capillary vessels, 
and tends to sustain life under the great depression from loss of blood. 

Sulphate of alum and sulphate of potass, in doses of fifteen to twenty grains ; 
or gallic acid, in doses of twelve grains, frequently repeated, i. e., every two, 
four, or six hours ; or infusion of matico or oil of turpentine, may each be used 
by turns, and according as the stomach will tolerate one rather than another ; 
but the sulphate of soda must not be given in conjunction with the acetate of 
lead. The efficacy of gallic acid is increased by combining it with fifteen or 
twenty minims of aromatic sulphuric add. It may also with benefit be com- 
bined with alum. Gallic add should have a fair trial, before giving acetate of 
lead. From two to five grains of ergot of rye (secale cereale), or the liquid ex- 
tract, in doses of twenty or thirty minims, frequently repeated, say every hour 
or half hour, has been of use. The oil of turpentine, to the extent of ten to 
twenty drops, is to be given in mucilage every two or three hours. 

Nutritive but non-stimulant food must be given in small quantities, and 
frequently. It is best given as animal jelly, coagulated soups, or soup in the 
jelly form, rather than in the fluid watery form. Alcoholic stimulants are to 
be avoided. One well-selected plan must be persevered in, so as to avoid 
capriciously and rapidly shifting from one remedy to another. 

As to local remedies, the actual cautery should never be employed, but 
every trust must be placed in gentle pressure over applications of strong tinc- 
ture of matico, and solution of the perchloride of iron. 

As a last efibrt in a case apparently hopeless, transfudon of blood may still 
be tried. 

Consult also the articles on Scurvy and Purpura. 



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DEFINITION AND PATHOLOGY OF DEOPST. 115 



DEOPSY. 

lii.TiN 'E,(i., Hydrops ; Pkknch Eq., i/i/c^ropme; GekmanEq., Wassersucht; Italian 

Bq. , Idropisia. 

Definition. — Dropsy is a contraction for Hydropsy, mid signifies the accumu- 
lation of a watery fluid in one or more of the serous cavities ; or a diffusion of watery 
fluid through the areolar tissue of the body, or its organs ; or a combination of all 
these conditions. 

Pathology — The distinctive characteristic of dropsy is in the nature of the 
fluid which forms the accumulation. The fluid is not liquor sanguinis, but 
water containing more or less constituents of the blood-serum. 

In the preceding pages, 81 to 83, the nature of the results are described, 
when liquor sanguinis, and blood, are effused as products of the inflammatory 
process. In dropsies, however, tiie fluid seems to be devoid of all coagulating 
elements, or of elements tending to growth or development. The liquid is 
clear, like the serum of the blood; and in the so-called "fibrinous dropsies," 
where the fluid contains coagulated fibrin in greater or less amount, the fluid 
is not the fluid of dropsy, but is generally the result of more or less inflamma- 
tion, involving the texture of the serous sac in which the fibrinous fluid is 
found. In all true dropsies the texture of the part where the fluid exists is 
unimpaired by inflammatory changes ; and the lesions giving rise to the 
dropsy must be sought for generally in some other organs of the body. The 
fluid collections in the pleura of pleuritis and hydrothorax contrast in these 
respects. The fluid of the former is the result of inflammation, and generally 
contains flakes of coagulated fibrin ; the fluid of hydrothorax is a true drop- 
sical effusion. The prefix hydro or hydrops is used to express the fact that the 
lesion is a true dropsy of a serous sac ; and dropsies receive different names 
according to their situation. Thus, dropsy of the belly, where the peritoneum 
is distended with watery fluid, is sometimes called hydroperitoneum, but is 
usually now called ascites ; dropsy of the brain or head, where the ventricles 
are distended with watery fluid, is called hydrocephalus ; dropsy of the chest, 
where the pleural sac is filled with serous fluid, hydrothorax ; dropsy of the 
pericardium, where that sac contains the fluid, hydropericardium ; dropsy of . 
the eye, hydrophtJialmia ; dropsy of the womb, hydrometra ; dropsy of the tunica 
vaginalis testis is termed hydrocele ; dropsy of the areolar tissue of a part is 
termed cedema, and is a lesion common to the areolar tissue of internal organs, 
as well as to the subcutaneous areolar tissue of the body generally. Hence 
there is mdema of the lungs and of the liver, and when fluid effusion exists in 
the tissue of these organs, they are said to be oedematous. When cedema of the 
subcutaneous areolar tissue is general over the body, this dropsy receives the 
name of anasarca ; and the combination of anasarca, with dropsy of one or 
more of the large serous sacs, is usually named general dropsy. There are 
also dropsies of other parts, which receive characteristic names. Thus, dropsy 
of the lachrymal sac Js called a fistula lachrymalis, or lachrymal hernia. 

The water of dropsy has the serum of serous membranes as the basis of the 
fluid accumulation ; but the exact constituents of the dropsical fluid differ in 
different cases as regards the ingredients held in solution ; and, generally in 
all, more of the water of the blood than of the solids of the serum passes out 
of the vessels in these dropsies. The specific gravity of the fluids also varies 
in diflferent parts, the fluid of hydrocephalus and spina bifida being the least, 
pericardial SinA ovarian dropsy- the greater. 

The following table gives the results of Dr. Marcet's analysis, but it greatly 
wants verification : 



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116 



TOPICS RELATIVE TO PATHOLOGY. 



In 1000 Grains of Fluid. 


Speoiflo 
Gravity. 


Total Solid 
Contents. 


Animal 
Matter. 


Saline 
Matters. 


Muid of Spina Bifida, . 

" Hydrocephalus, 

" Ascites 

" Ovarian Dropsy 

" Hydro thorax, 

" Hydrops Pericardii, .... 

" Hydrocele, 

" A Blister, 

" Serum of the Blood, .... 


1007.0 
1006.7 
10150 
1020.2 
1012.1 
1014.3 
1024.3 
1024 1 
1029.5 


Grains. 

11.4 

9.2 

33.5 

26.6 
33.0 ■ 

80.0 

100. 6 


Grains. 
2.2 
1.12 

2-5.1 

i8'.8' 
25.5 
71.5 

go'.s' 


Grains. 
92 
8 08 
8.4 
8.0 
7.8 
75 
85 
8.1 
9.2 



Generally, the fluid of hydroihorax will be lighter than that of pericardial 
fluid ; and the fluid of dropsy is but an augmentation of the kind of efiiision 
or secretion natural to the part, and not merely a sweating or escape of serum. 
In its reaction, the fluid of dropsy is mostly alkaline, but may be faintly acid 
or neutral : in its purity it is colorless, or pale straw color, and of a clear and 
limpid appearance, and in the quality of its ingredients it is analogous to the 
serum of the blood, although in consistence it is thinner. Chemically, it con- 
sists of water, albumen, fat (generally as cholesterin), pigments, extractive 
matter, and salts {chloride of sodium preponderating over the earbonaies and 
phosphates of alkalies'), and of alkaline earths. Urea is sometimes present 
when the kidneys are at fault. The albumen is subject to the greatest fluc- 
tuation ; and is generally pure as the albumen of blood-serum, or it exists 
as an albuminate of soda or othSr well-known forms, as well as in forms and 
modifications as yet unknown. The fluid of pleural dropsy (hydrothorax) is 
richer in albumen than the fluid of ascites (Lehmann) ; and there is still less 
albumen in the fluid of arachnoid dropsy, or that of the cerebral ventricles 
(hydrocephalus) than in the fluid of ascites. The fluid of dropsy into the sub- 
cutaneous areolar tissue {anasarca) is the poorest of all in albumen. When 
the albumen is in great abundance (as in the ascites from ovarian disease), 
the fluid becomes viscid and adhesive, like synovia. A red coloration is due 
to_ blood-pigment ; a yellow or yellowish-green, generally to bile-pigment ; a 
milky whiteness, opalescence, or whey-like turbidity, may be due to accidental 
mixture with epithelium or fat, as fine cholesterin crystals (often seen glis- 
tening in the fluid of old hydroceles), or it may be due to albumen precipitated 
by an excess of water relative to the saline contents. 

The origin of dropsy is due to several causes, acting singly or in two or more 
combinations ; and, like congestion, it may be sometimes purely mechanical, as 
(1) when it is the result of retention of blood in the veins through mechanical 
hindrance to the circulation. The interruption to the venous circulation as a 
chief cause of dropsical efiusion was first experimentally demonstrated by 
Lower, who tied the vena porta of a living dog, thereby causing its death by 
dropsy. The extensive distribution of the dropsical effusion varies in accord- 
ance with the site of the obstruction ; and is great in ptoportion as the cen- 
tres of the circulation are implicated. The fluid also will be in abundance 
proportionally to the fluidity or excessive wateriness of the blood {hydrcemia), 
and IS exuded mainly from veins. (2.) In dropsy resulting from general de- 
bility, hydrwmia in parts tlmt are paralyzed, effusion takes place mainly from 
capillary vessels. 

Thus three important conditions may act singly or in combination in the 
production of dropsy ; namely,— (a) Mechanical impediment to the circula- 
tion, and especially the free passage of blood through one or other of the great 
organs, namely, the heart, lungs, or liver; (6) Altered condition of the 
blood, by excess of water diminishing the density of blood-serum; or, by un- 



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ORIGIN OF DROPSY. 117 

eliminated excreta, such as biliary or urinary elements in hepatic or renal 
diseases ; (c) A poor, watery, exhausted blood. 

Dropsy is never a primary aifection, or substantive disease, but only a 
symptom of disease, and always dependent on some antecedent morbid condi- 
tion, the mechanism of whose action is implied in the physical conditions just 
mentioned. 

An important distinction is made between genefral dropsy and local dropsy. 
In the former, more or less extensive anasarca is associated with effusion of 
fluid into one or more serous cavities, especially the peritoneum or the pleura. 
The subcutaneous appearance of the fluid is generally expressed first by a 
puffiness of the face, especially in the morning, under the eyelids, and next in 
the feet and ankles in the evening, or in the hands and forearms, particularly 
the left ; or it appears at once in all of these seats, and gradually extends 
throughout the body, associated with which the accumulation in the serous 
cavities may be also considerable. 

All such cases of general dropsy at once point either to obstructive lesions 
affecting the central organ of circulation, or to a morbid condition of the 
blood, or to both combined. 

Associated with the first condition, it is a symptom of disease of the heart, 
and is then known by the name of cardiac dropsy. It is attended with great 
difficulty of breathing (dyspnoea), labored action of the heart, and livid con- 
gestion of the skin. Although called generally cardiac dropsy, it arises from 
obstruction to the current of blood through the heart, lungs, or liver ; either 
primarily in the heart — as in valvular disease of the left side — or primarily 
in the lungs, and secondarily in the heart — as in emphysema and chronic 
bronchitis, one or both producing dilatation and inefficient action in the right 
heart, and a consequent retrograde effect throughout the venous system. 

Associated with the second condition, general dropsy is usually a symptom 
of disease of the kidney ; and it is then known by the name of renal dropsy. 
Drs. Bright, Christison, and Gregory were the first to furnish numerous proofs 
of the frequency of structural lesion of the kidneys with dropsical effusions. 
The lesion of the kidney is generally some one of the varied forms of Bright's 
disease, in which the serum of the blood becomes greatly altered, being 
deprived of its albumen, which passes in the urine, and rendered impure by 
retention of excreta such as urea. The countenance and skin are especially 
pale in such cases. 

Associated with changes in the blood, general dropsy is sometimes a conse- 
quence of severe malarious poisoning, giving rise to protracted intermittent 
, fever, in which the blood becomes greatly altered, as in extreme ansemia ; and 
a similar general dropsy has been known to attend the ansemia of over-pro- 
longed lactation, and in chlorosis after large hemorrhages, or other exhausting 
discharges, also in starvation from deficient, watery, vegetable, or unwhole- 
some diet, as in the dropsy often prevalent among the poor in times of scarcity. 

In local dropsy, one serous cavity, or one organ, or one part of the subcuta- 
neous aseolar tissue, is the seat of the dropsical accumulation. The perito- 
neum is the most frequent serous sac so affected, and the accumulation is gen- 
erally the result of obstruction to the circulation through the liver by the ve.na 
porta, a result of hepatic disease generally in the form of the complex lesion 
known as cirrhosis, under which this form of dropsy will be more particularly 
described. But it may be here stated that the effect of the obstruction in the 
liver, as in cardiac dropsy, is carried back till its effects are felt in the reniotest 
capillaries of this section of the venous system; and hence the ascites which is 
the usual expression of such hepatic obstruction. An example of local dropsy 
may also be seen in the oedema of the lungs, resulting from the cardiac lesion 
of mitral obstruction. Fibrinous concretions obstructing the vena caw and 
internal iliac vems, or tumors, or a psoas abscess pressing upon these vessels, 



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118 TOPICS EELATIVB TO PATHOLOGY. 

are also sometimes causes of local dropsy. Disease, by enlargement of the 
spleen, gives another cause for local dropsy, and is often the result of malaria. 
Special details regarding dropsies will be found under the several lesions 
of which dropsy is a result.* 



FIBRINOUS DEPOSIT. 

Latin Eq., Fihrina Deposita; French Eq., D^pot Fibrineux : German Eq., Faser- 
stuffablagerung — Syn., Fibrinose Ablagerung ; Italian Eq., Deposito Fibrinoso. 

Definition A morbid condition in which a great tendency exists for fibrinous 

matter to separate from the blood, more or less rapidly, and to be deposited in va- 
rious parts. 

Pathology. — The exact nature of this form of lesion is -not well known, but 
if the quantity of fibrin be considerable at any one time, it forms a solid 
mass, of which, perhaps, the best examples are those large yellow pyramidal 
blocks often seen in the spleen. If, on the other hand, as is more common, a 
slow and gradual separation occurs, a formation of fibroid tissue takes place, 
causing thickening of membranes, or similar changes in more solid parts (H. 
Jones, Path. Trans., vol. vi, p. 96). These fibrinous deposits present a light 
red or yellowish white color, and occur in a more or less wedge-shaped form, 
with the apex centripetal and the base of the wedge towards the periphery of 
the organ. Miscroscopically the deposit consists of a granular material. 

Two views are entertained regarding the production of such deposits — 
namely, either that they result from minute particles of fibrin being continu- 
ously detached at points of the circulating system, more or less remote from 
the local deposit, but carried there by the current of the circulation ; or they 
have been regarded as an exudation of fibrin from the capillary circulation. 
(See Path. Trans., vols, iii, viii, xiii.) 

There are cases where a tendency, either on the part of the blood to pre- 
cipitate its fibrin, which seems increased in quantity, or there is a tendency 

* Pneumatoses, or the accumulation of various gases, both within textures, and more par- 
ticularly in every cavity of the body and of its organs, ought to find some notice here. 
It does not find a place in the new nomenclature of the College of Physicians. Eoki- 
tansky describes the modes in which gas accumulations originate, as follows: 

(a.) Gas accumulated in the textures or in cavities is generally atmospheric air, which 
has penetrated from without. For example, most kinds of emphysema, gas accumu- 
lations in the pleural sac, gas accumulations in the stomach, and perhaps also, the more 
rare instances of gas collections in the uterus and urinary bladder : also gas in the 
blood, after injury to veins, particularly those of the neck, are collections of at- 
mospheric air. Interstitial emphysema and pneumothorax are results of lesions of 
continuity, through wounds or ulcerations in the bronchial passages, or in the lungs. 
If air be long retained in any of those situations, it undergoes changes similar to what 
it undergoes in the lungs. Its oxygen becomes exchanged for carbonic acid, with the 
superaddition of aqueous vapor. 

But some gaseous accumulations are the products of decomposition ; as, for example 
gas development in stomach and intestines, the result of impaired and imperfect 
digestion. Its morbid increase constitutes flatulency and tympanitis ; the former term 
implying movement of the gas (borborygmus), and its final expulsion by mouth or 
by anus; the latter term implies its retention, causing distension, with augmented 
resonance on percussion of the abdomen. This tympanitis is sometimes witnessed to a 
painful extent in cases of lientery, where the great bowel gets so distended with gas and 
paralyzed by distension, that death has ensued with symptoms similar to intestinal 
obstruction. The mucous membrane itself is also believed to secrete gas. 

Such putrefactive gas development also takes place out of blood mass; or from 
decaying normal textures or morbid products, such as sloughing cancers. 

It has also been observed that the subcutaneous areolar tissue, when slightly inflamed, 
may secrete air in such abundance as to produce emphysema. Dr. Graves relates a 
ease in which gas was secreted to a considerable amount in the cavity of the pleura. 

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FIBRINOUS DEPOSITS. 119 

to the spontaneous coagulation of the fibrin, it being natural as to quantity, 
but thus altered in quality. Instances of this exist in cases of phlegmada 
dolens, especially those occurring as a sequence to typhoid fever. The ten- 
dency also exists in those cases where decomposing clots of fibrin are found 
at times in the cavities of the heart, especially in the appendices of the auri- 
cles (J. W. Ogle, Path. Trans., vol. vi, p. 32). 

Fibrinous deposits, or concretions of fibrin, -within the heart, are called 
polypi or fibrinow vegetations. When such fibrinous deposits are found in blood- 
vessels, having been carried from a distance into them, and not formed where 
they are found, the term Emboli has recently been applied to denote such 
deposits. 

ALTERATION OF DIMENSIONS. 

Latin 'Bq, , Magnitudo Mutata; French 'Eq., AllSrations de Dimension; German 
Eq , Verdnderungen der Gestalt und Grosse; Italian Eq., Cangiamenti di Dimen- 
sione. 

Definition. — Alteration of dimension is expressed by an increase or decrease 
in the volume or bulk of an organ when compared with the normal volume as ex- 
pressed by the cubic inches of water it will displace. 

Pathology. — Such alterations of dimensions are comprehended under the 
following lesions — namely, dilatation, contraction, hypertrophy, atrophy. The 
terms dilatation and contraction are usually applied to hollow organs, such as 
the heart; while hypertrophy and atrophy have reference to an increase or 
diminution of the specific texture composing any organ or part. 



(a.) DILATATION. 

Definition — Expansion of the walls of a cavity, so as to inclose greater con- 
tents. 

It is generally coupled with hypertrophy of the walls of the dilated organs, 
when it is known as active dilatation. When the inclosing walls of the cavity 
are of normal thickness, the dilatation is known as simple dilatation ; conjoined 
with thinning, attenuation, or atrophy of walls, it is known as passive dilator 
tion. 

The causes of dilatation of hollow organs may be expressed as follows : 

1. Mechanical impediments, obstructing the free passage and egression of the 
contents of the different canals and reservoirs, and occasioning dilatation 
either beyond or behind the impediment. 

They are expressed in the following lesions ; namely : 

(a.) Constriction of calibre, through pressure from without ; e. g., by ab- 
scess or tumors. 

(6.) Coarctation or stricture, consequent upon hypertrophy and change of 
texture in the walls of the organ. 

(e.) Foreign bodies, or secretions obstructing canals. 

2. Paralysis of the contractile elements in the walls of the organ. 

3. Degenerative lesions. 

4. Inflammations. 

Dilatation tends to destroy life through paralysis, simply, or by the con- 
currence of asthenic inflammations, or by gangrene, the retained contents of 
dilated cavities contributing, by decomposition, to pnewnatoses and farther 
dilatation, as in paralysis with distension of the large intestine and urinary 
bladder. 



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120 TOPICS KBLATIVB TO PATHOLOGY. 



(J.) CONTEACTION. 

'Definitio'D..— Contraction, coarctation or stricture, are also terms applied to 
diminished capacity or calibre of hollow parts or passages, — such, for example, 
as heal contraction of bile-duets, or of urethra, or (esophagus, stomach, or any part 
of intestinal canal. 

(c.) HYPEKTEOPHY. 

Definition. — A lesion in which the enlargement of a part is effected by in- 
crease, growth, or development of its natural tissue, with proportional retention of 
its natural form, and with increase of power in proportion to increase of growth 
(Paget). 

Pathology. — Hypertrophy of the heart is a common example ; and, in its 
genuine form, the muscular tissuie is developed to more robustness. Its fibres 
become not only larger or more numerous, but firmer, more highly colored, 
and stronger. It is an instance in which the individual elements of the 
structure take up a considerable amount of matter,- and thereby become 
larger ; by which, and in consequence of the simultaneous enlargement of a 
number of elements, at last the whole of an organ may become swollen or 
enlarged. When a muscle becomes thicker, all its primary fasciculi become 
thicker. So also a liver becomes enlarged by hypertrophy, simply in conse- 
quence of a considerable enlargement of its individual cells. It is a genuine 
hypertrophy without new formation (Viechow). In the pregnant uterus 
also, such fibres are formed as are not seen in the unimpregnated state. They 
are not a new kind of fibre, but they differ in size and shape, and are much 
more powerful than those which compose the uterus in its unimpregnated 
condition. It is an enlargement of the organ effected through increase by 
development of its natural tissue. It is the hyperplasia of Virchow. Such 
hypertrophy of pregnancy is natural ; but it is imitated in disease, when, by 
the growth of fibrous tumors in the uterus, the womb attains the size, the 
structure, and full capacity of action of the pregnant organ, so that even the 
course of labor is imitated, and the fibrous tumor is expelled by the con- 
tractile power of the uterus, as if it had been a foetus (Paget). Hypertrophy 
involves an abnormal activity of nutrition, and also at the same time pre- 
serves the proportional natural form of the part. Thus simple hypertrophy 
is scarcely to be distinguished from the results of nutritive irritation; but, on 
the other hand, mer6 nutrition increase, mthout irritation (which is equiva- 
lent to exercise), will not produce hypertrophy. Mr. Paget, therefore, has 
well stated the essentials for hypertrophy to consist of the following condi- 
tions, namely : 

1. Increased exercise of a part in its healthy functions (or irritation short of 
exciting inflammation^ 

2. An increased accumulation in the blood of the particular materials which a 
part appropriates to its nutrition or in secretion. 

3. An increased afflux of healthy blood. 

As examples of the first, the arm of a strong blacksmith, whose muscles 
acquire bulk and power from constantly recurrent and vigorous contraction 
from exercise in the use of the hammer, or the great robust heart of a man 
who has suffered from some disease producing an obstacle to the movement of 
the blood. In the great majority of cases of hypertrophy of the heart, the 
lesion is due to valvular disease, which presents an obstacle to circulation of 
blood through the organ. So also is the urinary bladder hypertrophied in 
consequence of stricture of the urethra. "The bladder," says Mr. Hunter, 
"in such cases having more to do than common, is almost in a constant state 
of irritation and action, by which, according to a property in all muscles, it 

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DEFINITION AND PATHOLOaY OF HYPERTROPHY. 



121 



becomes stronger aud stronger in its nruscular coat ; and I suspect tliat this 
disposition to become stronger, from repeated action, is greater in the involun- 
tary muscles than the voluntary ; and the reason why it should be so is,_I 
think, very evident, for, in the involuntary muscles, the power should be in 
all cases capable of overcoming the resistance, as the power is always per- 
forming some natural and necessary action ; for whenever a disease produces 
an uncommon resistance iu the involuntary parts, if the power is not propor- 
tionally increased, the disease becomes very formidable ; whereas, in the vol- 
untary muscles there is not that necessity, because the will can stop whenever 
the muscles cannot follow ; and if the will is so diseased as not to stop, the 
power in voluntary muscles should not increase in proportion" (Mr. Paget's 
Catalogue of College of Surgeons, vol. i, p. 3; and Hunter's work, vol. ii, p. 
299). "Thus it is that the oesophagus, the stomach, the intestinal canal (as 
often as any portion is the seat of stricture) becomes hypertrophied as to its 
muscular coat above the seat of stricture. 






DiaRrams of hepatic cells.— (^.) Their simple physiological appearance. (B) Hypertrophy ;^ a, sim- 
ple • b with accuiuulation of fat (fatty deseiieration, fatty liver). (C.) Hyperplasy (numerical luorease 
M acljimctive hypertrophy); a, cell with nucleus and divided nucleolus; b, divided nuclei; c, c, divided 
cells. (After Viechow.) 

It is Still undecided whether, in muscular hypertrophy, the increase of size 
is owing exclusively to enlargement of primitive fibrillaj, or whether new fib- 
rilke are produced. If new fibrilla are produced, the enlargement, accord- 
ino- to Virchow, would be hyperplastic and not hypertrophic. In hyperplasia 
new or more numerous anatomical elements are generated, which contribute 
to the enlargement of a part, by real increase of new material, and which 
must be distinguished from that enlargement of a part which is a genuine 
hypertrophy. It will thus appear obvious that mere enlargement of a part is 
not necessarily hypertrophy of the part; and, therefore, it is important patho- 
logically to distinguish real hypertrophy from apparent or false hypertrophy A 
liver or spleen enhirged by lardaceous degeneration furnish examples of fake 
hypiertroplaj ; such liver or spleen, as to structure, being really in a state of 
atrophy from wasting of the normal elements. 

Cases in which an enlargement takes place in consequence of an increase m 
the mimber of the elements, are examples of hyperplasia. Thus, a liver may 
become enla'ro-ed by a very abundant development of a series of small cells 
in place of the ordinary cell development ( c, Fig. 10, ante). Hyperplasia may 
therefore be considered as a numerical hypertrophy, due to a proliferation or 
reproduction of tissues similar to the original part, and the condition ot the 
pregnant uterus is thus one of hyperplasia rather than genuine hyjiertrophy. 



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122 TOPICS RELATIVE TO PATHOLOSY. 



(d) ATEOPHY. 

Definition. — A deficiency of the formative process, by which a part simply wastes 
and is reduced in size, with little or no change of texture, or with gradual and eon- 
tinuous degeneration (Paget). 

Pathology. — As, there are two forms of hypertrophy — the one with growth, 
the other with development (the hyperplasia of Virchow)— so there are two modes 
of atrophy ; the one with simple decrease, the other with gradual and continuous 
degeneration of tissue. In both forms, there is invariably a loss of functional 
power in the part : but, in the one form — that of simple decrease — the loss is 
due to deficient quantity ; in the other form — that of degeneration — ^the loss is 
due to deteriorated quality of the tissue. Atrophy does not necessarily imply 
diminution in the bulk of an organ. The atrophied organ may, in reality, 
be increased in size, as in the false hypertrophies already noticed, especially 
fatty and lardaceous degenerations. Atrophy is sometimes a natural process, 
as in the decline of gland textures, when the need for their existence, or 
natural term of their special life, has ceased ; for example, the thymus gland, 
Peyer's patches after forty or fifty years of age, the ovary, testicles, and gen- 
ital parts generally in old age. Progressive atrophy of all the organs and tex- 
tures is incident to old age, and is called senile atrophy. In some instances cer- 
tain tissues waste continuously or progressively; for example, the muscles in 
that form of disease which will be described as "progressive muscular atrophy," 
and where the volume of the affected muscles is markedly diminished, as they 
become successively implicated in the disease. Atrophy, with diminution of 
volume, is also illustrated in certain chronic diseases of the kidneys, marked 
by contraction of their bulk ; and also in cirrhosis of the liver. The emacia- 
tion of scrofula, with or without tubercle, is an example of atrophy afiecting 
the fatty or adipose tissue especially ; and it is especially expressed by the 
terms phthisis, consumption, marasmus. It is thus a general atrophy ; and its 
efiects exhibit themselves in the wasted appearance of the body as a whole. 

The conditions giving rise to atrophy may be shortly stated as the opposite 
or reverse of those producing hypertrophy, already noticed. 



DEGENERATION. 

Latin Eq., Degenera.tio ; Pkbnoh Eq., Degenireseence ; &ekman Eq , Degeneration — 
Syn , Entartung ; Italian Eq , Degenerazione. 

Definition. — Degeneration of tissue implies such a departure from the normal 
state as gives rise to a granular disintegration or detritus within its minute ele- 
ments, or to any deterioration by exudation or deposit, which, by the functional 
actions of repair in the normal state, could not have been left in the texture. 

Pathology. — The separation of degenerations from substantive diseases is 
one of the greatest advances in modern Medicine, as Sir William Jenner has 
well shown in the address to the British Medical Association at Leeds, July 
28, 1869. 

By degeneration is meant, — 

(1.) Retrograde metamorphosis; and what is that? Shortly, it may be 
^stated, that we are always changing, therefore something is always being 
removed and replaced ; but in degeneration a passive change goes on, distinct 
from living processes. The result is a granular disintegration of tissue. 

This is_ especially expressed in the form of fatty degeneration, rotting and 
'Calcification, or petrifaction. These same changes occur post mortem, and after 
tissues are removed from the body and preserved in the bottles of the museum. 

(2.) Changes accompanied by thickening by hyperplasia generally, and 
diminished elasticity of certain tissues, occurring especially in advancing life. 



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IMPORTANCE OF RECOGNIZING DEGENERATIONS. 123 

The general diffusion of these degenerations is characteristic of advancing 
age. The circumstances under which degenerations occur are of the nature 
of decay and death. For example, degeneration occurs to an immense extent 
in the tissues of the aged, especially in the heart and arteries, and to a less 
extent in the voluntary muscles and the hard textures. Towards the close of 
the life of a part of the body, degeneration takes place ; as, for example, in 
the textures of the placenta, when utero-gestation is nearly complete. To 
such degenerations Virchow has given the name of necrobiosis, because death 
and degeneration seem to be brought about by altered life at the close of 
natural existence. In this respect it may be truly said, that " As we begin to 
live we begin to die." "To degenerate and die is as normal as to be developed 
and live." A spontaneous wearing out of living parts goes on, so that de- 
struction and annihilation are immediately consequent upon life. 

Alterations in consistence are marked characteristics of degeneration. Elas- 
ticity is impaired, and softening is often the ultimate result of such degenera- 
tion, which becomes palpable chiefly by the decided friability of the parts. 
The minute elements of tissue lose their coherence, and at last really liquefy, 
so that pulpy or fluid products . take their place. When it is remembered, 
also, how abundantly a granular fatty transformation occurs after death, the 
nature of degenerations becomes more intelligible ; and my friend Dr. Lyons, 
Professor of Medicine in the Catholic University of Ireland, instituted a series 
of observations which beautifully demonstrated a process of morphic changes 
of tissues through dissolution and decay, till the mortal parts of our body 
return " ashes to ashes " and " dust to dust." To these morphic changes he 
has given the name of " Histolysis." To the same end are the demonstrations 
of Dr. Quain, regarding the conversion of muscle into fat, and of crude flesh 
generally into adipocere, accounting for the enormous fattiness of certain geo- 
logical strata in which animal remains are abundant (MiCHiELis, quoted by 
Simon). Such experiments and observations as those of Panum, Melsens, Asch- 
erson, Gluge, Lyons, Simon, Burdach, Wagner, Michselis, and others, and in 
which granules, vesicles, and cell-forms appear to rise spontaneously out of 
homogeneous albuminous fluid, will go far to explain many of the conflicting 
accounts which are given of the nature of the inflammatory products just 
described, and of the degenerations. Such forms may undoubtedly arise, as 
these observers show ; and having arisen, they decompose and advance through 
changes such as Dr. Lyons has described under the name of histolysis. On the 
other hand, the productive results of inflammation undoubtedly grow from pre- 
existing tissue-elements, as already described. From this point of view, struc- 
tural changes in the valves of the heart are the result of one of three con- 
ditions : 

(a.) Imperfect development. 

(b.) Endocarditis. 

(e.) Degenerative changes. 
These last rarely occur till middle life ; not usually till advanced life in civ- 
ilians. They seem to be frequent in soldiers at early ages. 

Our knowledge of such degenerations enables us to appreciate lesions of 
cerebral textures following such degeneration of arteries and the capillaries of 
the brain. 

Degenerative changes in coats of larger arteries can be traced in series up 
to aneurisms through all stages of local dilatations. They do not occur in 
childhood or early youth ; they are concomitants of old age especially, but are 
seen at early ages amongst soldiers. 

All the degenerations are examples of atrophy with changes of texture 
(Paget), as distinguished from atrophy resulting from simple decrease of bulk, 
the organ or tissue otherwise retaining its usual form, and to some extent its 
flinction. To recognize the following degenerations of tissue after death, the 
employment of the higher powers of the microscope is essential. 

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124 TOPICS RELATIVE TO PATHOLOGY. 

The recognition of the following degenerations has very much modified our 
practice and opinions of recent years, e. g., the diagnosis and treatment of 
degenerative heart diseases, also of certain forms of apoplexy. In illustration 
of this, Sir William Jenner gives the following apt illustration in one of the 
most terse and suggestive lectures of^the time : 

"Although with regard to the virtues of this or of that particular drug, and 
to the mode of action of this or of that particular class of remedies, there is, 
and always will be diiferences of opinion — the evidence that satisfies A. being 
insufficient from the constitution of his mind to satisfy B. — with regard to the 
value of drugs in the abstract, with regard to the value of treatment, there is 
really little difference of opinion among physicians equally well informed as 
to the present state of medical knowledge, and equally experienced in 
practice. 

" I say, among men equally well informed. Let me illustrate my mean- 
ing. I was one of three who met in consultation concerning a case of apo- 
plexy. In the opinion of one of my colleagues and myself, the only treatment 
to be adopted was as follows : To place the patient in the recumbent position, 
with head and shoulders raised, to enforce absolute rest, to keep the bowels so 
far loose as to prevent excitement and straining ; to apply cooling substances 
to the head in the event of any heat of the part occurring ; to support the 
patient with light nutritive food, having regard to his habits. The third gen- 
tleman protested a,gainst the modern system of doing nothing ; he was anxious 
to bleed, to purge, to blister ; and, when opposed, was not sparing of the term 
skeptic, &c. 

" Now, the difference of opinion in this case was not due to skepticism on the 
one side and justifiable faith — i. e., faith justified by knowledge — on the other ; 
but to knowledge on the one side,, and absence of knowledge on the other. 

" The case was one of degenerative change, retrograde metamorphosis, of the 
arteries ; one had become so rotten that its wall had given .^.way, its contents 
had escaped, a clot had formed, and by its mechanical effects had given rise 
to the symptoms. The heart shared in the degenerative changes ; the bleed- 
ing had ceased. To those who understood the real nature of the case the lesions 
present, and the mode in which they had been produced — in short, the pathol- 
ogy of the case — belief in the efiicacy of so-called active treatment appeared 
to be not merely unjustifiable faith, foundationless faith, faith without knowl- 
edge, but to be faith in opposition to knowledge, which in Medicine is the worst 
form of skepticism, inasmuch as it is doubt of truth and belief in error — doubt 
which may prevent the saving of life, and belief which, embodied in practice, 
may kill" {The Practical Medidne of To-day, p. 4). 



(a.) Fatty Degeneration. 

Amongst the degenerations which are brought about by the spontaneous 
wearing out of living parts, the most widely spread, and the most important, 
is unquestionably fatty degeneration. It is attended by a continually increas- 
ing accumulation of fat, which replaces the minute elements of tissue in dif- 
ferent organs ; and Simon concludes generally, regarding the presence of such 
oil or fat in textures uninfiamed, that it is essentially a sign of weakness or of 
death, representing decomposition of efiective material. In such necrobiosis 
the elements of the normal tissue completely perish, and are replaced by fat- 
granules. 

Examples of this degeneration may be seen in the minute elements of 
muscle, especially of the heart ; in the acini of the liver, contiguous to the 
capillaries into which the branches of the portal vein break up. In such 
degeneration the cells ultimately disappear, lea'ding to loss of substance and 
atrophy of the gland. It may be seen in the bloodvessels, in the corpora lutea 



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• CAUSES OF FATTY DEGENERATION. 125 

of the ovaries, in the renal epithelium, and in many pathological products, 
such as pus, tubercle, cancer, and the like, when in process of decay ; and, in 
short, in nearly all cell-structures, this degeneration is known to occur. 

In every texture this degeneration becomes evident in a similar manner. 
Isolated, extremely minute globules of fat appear in the substance of the cells, 
and becoming more abundant, they gradually replace the normal cell-ele- 
ment. Usually the fat-granules appear at some distance from the nucleus ; 
but ultimately they lie as close to each other as in the colostrum corpuscles of 
milk. At last the nucleus is no longer visible, and the membrane of the cell 
finally disappears — probably by a species of solution. If the degeneration 
occurs in the more rigid structures — as, for example, in the walls of arteries 
— ^the fatty granules retain the form of the cell-structure which they replace. 
Such degeneration in arteries is first seen in the tissue composing the inner- 
most layer of the internal coat. Afterwards the intermediate substance 
softens, the degenerate fat-granule masses fall asunder, and the current of 
blood may carry away the particles of fat with it. Thus a number of uneven 
places (cicatricial-like loss of tissue) may be produced upon the surface of the 
larger vessels without any appearance of ulceration (Vikchow). 

In fatty degeneration of the substance of the heart there is discoloration 
of its whole substance. It assumes generally a pale yellow hue, with peculiar 
spots on the papillary muscles. Short yellow streaks, which communicate 
with each other, are to be seen in the direction of the primitive fasciculi, and 
pervading the substance of the papillary muscles. 

Yellow softening of the brain is a form of fatty degeneration ; and the 
yellowness is due to the accumulation of finely granular fat. At every point 
where fatty degeneration attains a high pitch, great opacity always presents 
itself The primitive cells of tissues are always transparent in their normal 
state; but fat in excess renders them opaque. Thus a transparent part 
becomes opaque, as in the cornea, where the fatty clouding marks the areus 
senilis, described by the late Mr. Canton, in persons past middle life, and 
regarded by him as an index to the existence of fatty degeneration of other 
more important organs, although the importance of the sign may have been 
exaggerated. In some form of Bright's disease the uriuiferous tubules become 
filled with fattily degenerated epithelium, which appear as opaque spots on 
the surface of the kidney. 

Additional examples of this fatty degeneration are to be seen in the fatty 
liver, and in mollities ossium, atrophied renal capsules, and thymus gland, and 
the muscles — voluntary as well as involuntary — the fatty degenerations of the 
placenta, of cartilage, of bone, and of morbid growths ; indeed, there is no 
kind of tissue, healthy or morbid, which may not undergo fatty degeneration. 

When the normal structure of the part is thus transformed into fat, it is 
ultimately destroyed, and the place of the histological elements is gradually 
occupied by a purely emulsive mass — a kind of milk or fatty debris — that is, 
an amorphous accumulation of fatty particles in a more or less highly albu- 
minous fluid (ViECHOw). 

Practically it is of importance to know what leads to such degeneration. 
The conditions are mainly as follows : 

(a.) Impediment to the flow of blood to the textures, due to calcification 
or petrifaction of the coats of arteries. Anything damaging to nutrition of a 
part favors such degeneration. 

Thus the hypertrophied heart ceases in time to yield the proper physical 
signs of hypertrophy. Degeneration comes on, and the signs of hypertrophy 
are obscured and ill-expressed, being overlaid by those of degeneration. 

Thus, in hypertrophied hearts, degeneration is really a preservative lesion. 

From this point of view we ought always to discriminate clinically valve- 
lesions arising from endocarditis, as distinguished from degenerative changes 



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126 TOPICS RELATIVE TO PATHOLOGY. ^ 

due to old age and other causes, and also distinguish the results of changes 
due to structures damaged from acute inflammation. 

Fatty heart and fatty arteries are concomitants. 

With reference to fatty degeneration in particular organs, see the account 
given of local diseases. 

(6.) Mineral Degeneration — Petrifaction. 

The process followed by tissues undergoing this form of degeneration is very 
similar to that described in the previous paragraphs ; but it is necessary to 
distinguish forms of mineral degeneration as distinct from ossification. 

Formerly every kind of tissue condensed to the same degree of hardening 
as a bone was considered to be ossified, and the condition was described as 
" ossification." But although a part may have lime in its intercellular sub- 
stance, and although stellate cells may be present in it, yet it may be merely 
" calcified " or "petrified " tissue, and this condition Virchow briefly described 
as "petrifaction." 

Pathological ossification presupposes that the tissue or part which ossifies is 
called into existence by growth, and not that a previously existing tissue or 
part merely assumes the form or hardness of bone by absorbing calcareous 
salts. Ossification always begins by a growth of new tissue ; and deposition 
of calcareous salts in its substance does not take place till a comparatively 
late period. 

Calcification or Petrifaction is a degeneration comparatively more frequent 
in the peripheral arteries, and occurs most commonly in cases where there is 
a tendency to calcifications generally, and where calcareous salts are set free 
at other points in the system, to circulate with the juices (Virchow). 

The lesion, in its purity or genuine form, is to be distinguished from athe- 
roma of the arteries, which implies a combination of the fatty with the cal- 
careous material — the so-called ossification. In both conditions the artery 
may be felt to be a hard and rigid tube, with a calcareous feel to the knife or 
the touch. A careful examination microscopically will show that the degen- 
eration is in the middle coat, that calcification or petrifaction of the minute 
muscular cell-elements has taken place, and that the fibre-cells of the circular 
fibre coat are transformed into calcareous spindle-shaped bodies, mixed with 
more or less fat. The degeneration may also invade surrounding parts, while 
the internal coat of the artery may be unchanged. The larger arteries are 
often brittle, from the mineral degeneration of their tissue — associated with 
fatty degeneration (atheroma). Patches or plates of the mineral substance 
may be seen imbedded in the middle coat after the inner membrane is stripped 
oflf. When the smaller vessels undergo the mineral degeneration, the deposit 
resembles particles of oil ; and the nature of such an appearance can only be 
determined by the microscope after the application of mineral acids, which 
will dissolve the mineral matter with effervescence. 

Nerve-cells, the fibrous membrane of the brain, the pia mater, and the 
choroid plexus, are all liable to undergo the mineral degeneration. Exu- 
dations and new growths are similarly liable. Dr. Bennett has seen the gall- 
bladder converted into a calcareous shell, and the pericardium into an un- 
yielding box of mineral matter inclosing the heart. The cardiac valves are 
thus often covered with mineral incrustations. Cancer and tubercle-growths 
may be transformed by the mineral degeneration ; and Dr. Bennett has shown 
how the calcareous transformation of tubercles is the natural mode of arrest- 
ing their advance. 

The degeneration may follow upon the metastasis of calcareous salts, not 
excreted by the kidneys, in cases of caries of the bones, necrosis, or osseous 
cancer. I have seen specimens in the most mteresting collection of Professor 

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PIGMENT DEGENERATION. 127 

Virchow -which show that metastatic deposits of bone-earth have taken place 
in the lungs and in the stomach under such circumstances. Considerable 
portions of the pulmonary tissue were calcified or petrified, without any appar- 
ent injury to the permeability of the respiratory passages. The lesion in the 
lung looked like a portion of fine bathing sponge. The mucous membrane 
of the stomach was in like manner transformed into a calcified ot petrified 
mass. It felt like a rasp, and grated under the knife, so that the stomach- 
tubes seemed imbedded in a stiffened mass. The basis of such degeneration, 
in which the lime-salts find a resting-place, are the fine fibrous or connective 
tissues ; and hence the degeneration is seen to occur in fibrous tumors, in 
serous membranes, in the parenchyma of lungs and stomach (as in the in- 
stance just mentioned), in cicatrix tissue on the skin, in the valves of the 
heart, in the connective tissue of muscle sheath, as well of the heart as of 
common muscle ; in the tunica albuginea, in the fibrin coagula in the heart's 
cavities, in aneurismal sacs, and in the thyroid and pineal glands. The creti- 
fication of fibrin, of pus, of tubercle, of cancer, of vegetations, of coagula, all 
pertain to this form of degeneration ; and the process may be traced through 
all stages of progressive degeneration, from the pulp-like condition to cement- 
like, compact, calculous concretion, as in the phlebolite of veins ; also in the 
turbid, chalky, speedily condensing juice of the cysts of the choroid plexus, 
and the cell-incrustations of the pineal gland concretions, as well as in the 
calcification of sarcomata and cancers. With regard to the degeneration as 
seen in tumors, Mr. Paget describes two methods by which it advances — 
namely, a peripheral and an interstitial calcification. The former is the rarer 
of the two. In this form of degeneration the fibrous tumor is seen to be 
coated with a thin, rough, nodulated layer of chalky or bone-like substance. 
In the interstitial form the degeneration is interspersed throughout the tumor, 
and so arranged that by maceration a heavy hard mass is obtained, variously 
knotted and branched, like a lump of hard coral (Paget, Surgical Pathology, 
vol. ii, p. 139). 

(c.) Pigment-Degeneration — Pigmentation. 

In this degeneration pigment takes the place of the minute tissue-elements, 
as fat or lime did in the previously-described conditions. It is seen in mucus- 
corpuscles, as in catarrhal pneumonia, in the pulmonary epithelium, in the 
acini of the liver, in the epidermic tissue, in the corpuscles of the blood in 
ague and melancemia. As in the former degeneration, so in this one, a dis- 
tinction must be carefully made between fat granule-cells and pigmentation, 
for in both cases apparently the same image is offered to view. 

The fat granule-cells appear as brownish-yellow corpuscles, but their indi- 
vidual particles have no positive color ; whereas the pigment-cells contain 
unquestionable gray, brown, or black molecules of pigment, which are opaque 
(ViECHOW). The diagnosis between the two is important, as in the brain, 
for example, where both sorts of granule-cells, namely, pigment-cells and fat- 
cells, may exist side by side. The former points to apoplexy having existed,, 
the pigment originating probably in a solution of the coloring matter of the 
effused blood, the fat to cerebral softening. Therefore it is of importance for 
the pathological interpretation of the diseased condition to distinguish between 
pigment and fat in the granular form. Such pigment or coloring matter is 
insoluble in potash and acids — even in nitric acid. 

In mucus-corpuscles or catarrhal cells the pigment exists in the form of 
grayish-black granules. They give rise to the smoky gray spots which are 
brought up in great quantity in the sputa in catarrhal states of the pulmonary 
passages ; and to an extreme degree where accumulating masses of prolifer- 
ating epithelium take place, as in catarrhal pneumonia and in the phthisis of 



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128 TOPICS RELATIVE TO PATHOLOGY. 

colliers, so well described by Dr. Wm. Thomson (Med.-Chir. Trans., vols, xx 
and xxi). 

In the condition known as melancemia (which, like leukoemia, has cells cir- 
culating in the blood, having made their way into it from definite organs) 
the cells contain black pigment ; in the latter case (leukoBmia) the cells are 
colorless. In melancemia colored elements are met with in the blood which 
do not belong to it (Stiebel, Viechow, Schonlein, Heineigh, Meckel, 
Feeeichs, and Tigri). These pigment-cells in the blood were first seen to 
occur in melanotic tumors, and were supposed to be due to the passage of 
particles from the tumors into the blood. This is not yet verified by obser- 
vation. On the other hand, it is to enlarged spleens pervaded by black pig- 
ment that the change in the blood is to be ascribed in such cases, the color 
being due to the absorption of colored particles from the spleen. The class 
of cases which are the most fruitful source of black pigment in the blood are 
those of malarious diseases, e. c/., intermittent fevers, and especially in persons 
who have been long afflicted with a considerable enlargement of the spleen. 
In such cases, Virchow, found in the blood of the heart cells containing such 
pigment ; and the cells that bore the color resembled in size and form the 
colorless blood-corpuscles ; but there were also other cells of an oblong form 
and nucleated, within which a greater or less number of large black granules 
were to be seen. It is in the more severe forms of intermittent fever that 
such pigment-degeneration occurs. Such pigment is seen to accumulate in 
the minute capillaries of the brain, attaching to the points of division of the 
small vessels, and sometimes associated with the comatose and apoplectic 
forms of intermittent fever. Such pigment is also seen in the minute hepatic 
vessels (Feerichs), where it ultimately gives rise to atrophy of the paren- 
chyma of the liver. In a specimen of liver preserved at the museum of the 
Military Medical School, a deposition of melanotic pigment in a granular 
form is visible amongst the interlobular connective tissue, following mainly 
the course of bloodvessels in an irregular manner ; and this case, like all the 
others yet recorded, was associated with a large black spleen. The contami- 
nation of the blood in these cases seems due to a degeneration commencing in 
the spleen. 

In post-mortem lesions the textures are thus seen to be very variously tint- 
ed, red, yellow, brown, green, or black, generally resulting from chemical 
alteration in the coloring matter of the blood or bile. The red pigments, as 
a rule, are due to the altered hsematin, originally of a yellow color ; and 
which is the common origin of three difierent kinds of crystals : (1.) Crystals 
of Hcematoidin are the most frequent products of blood-degeneration (Vie- 
chow). (Fig. 9, p. 113, ante.) These are formed spontaneously in the body 
out of hsematin ; and in their most perfect form present the shape of oblique 
rhombic columns, of a yellow-red color, or, in thicker pieces, of a deep ruby- 
red. In little plates it frequently bears a considerable resemblance to uric 
acid. In the majority of cases the crystals are of extreme minuteness — diffi- 
cult to see clearly, even with a power of 300 diameters. They are insoluble 
in alcohol, ether, dilute mineral acids, and alkalies ; and exhibit a peculiar 
play of green, blue, rose-tint, and yellow colors, under the action of concen- 
trated mineral acids. If large masses of extravasated blood continue to lie 
for any length of time, this is the substance into which the blood is trans- 
formed. An apoplectic clot in the brain, for example, is repaired by a large 
portion of the blood undergoing this transformation, and the color of the re- 
sulting cicatrix is due to the crystals of hxematoidin. When a young woman 
menstruates, also, the cavity of the Graefian vesicle, from which the ovum 
escaped, becomes filled with coagulated blood, and ultimately hcematoidin 
crystals are the last memorials of the event (Viechow). Hcematoidin is also 
allied to the coloring matter of the bile. 

(2.) Crystals of Hcemin, arising out of hcmatin, differ from hcematoidin in 

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DEFINITION OF LARDACEOUS DISEASE. 129 

this, that hitherto they are only known as artificial products which have not 
yet been seen in the human body. They are of a dark-brown color. (3.) 
Rectangular crystals or spicules of Hwniato-arygtalline. 

The yellow pigments are due to blood very much dissolved or dispersed, as 
in ecchymosis, or to bile, when it is absorbed in the blood and tinges all the 
textures. Coloring matter due to bile may be recognized in the urine by the 
play of colors it gives with nitric acid. A small quantity of acid gives a green 
hue ; and, as more acid is added, blue, purple, violet, and a red or brown- 
yellow color will ultimately appear. Of the brown and dark pigments there 
are two kinds. One kind loses color on the addition of nitro-muriatic acid or 
chlorine water ; the other resists not only these agents, but even the action of 
the blow-pipe. This latter pigment consists of carbon. The former is a pecu- 
liar secretion formed within cells, or is a transformation of the coloring matter 
of the blood (Bennett). Blue and purple pigments have been seen in urine 
containing uroxanthin, or the Indican of Schvmk ; and illustrate the close con- 
nection subsisting between animal and vegetable coloring matters (Parkes On 
Urine, p. 198). For much more interesting observations on the nature of 
pigmentation, consult Bennett's Principles and Practice of Medicine, p. 249. 

(d.) Fibroid Degeneration. 

Definition. — A very gradual transformation of tissue, with scarcely any percep- 
tible exudation of material capable of growth, into a material having a fibre-like 
appearance. 

Pathology. — This fibroid transformation is chiefly found in membranous 
structures. It takes part in the gradual thickening of serous membranes and 
areolar tissue ; and on the surface of such organs as the spleen and pericardium 
covering the heart (white spot), it very much resembles cartilage, by its dead 
white appearance, as if the capsule of the spleen or covering of the heart had 
undergone cartilaginification (Rokitansky). But there is no resemblance 
beyond appearance between the degenerate formation and cartilage. The 
capsule of the liver is sometimes similarly thickened, and so are the sheaths 
of the vessels composing the capsule of Glisson similarly impaired in some 
forms of cirrhosis. The degeneration is the result of long-continued pressure 
(condensation), perhaps with friction ; or may be a sequence of chronic inflam- 
mation with an exudation. It is a form of sclerosis telw cellubsce of new-born 
children (hide-bound''. It takes part in the wheals and knolls of skin in 
elephantiasis, and constitutes cicatrix tissue. In synovial membranes it ap- 
pears first as a fibro-serous plate, of milk-white hue, from which the serum is 
ultimately expelled, leaving a dense fibroid band of union, or a thickened, 
opaque, bluish-white, tough patch, as in the arachnoid, pleura, peritoneum, 
pericardium, and endocardium. It is especially so on the heart's valves, which 
become rough, indurated, and thickened under the influence of this degenera- 
tion. 

LARDACEOUS DISEASE — SYN., AMYLOID DISEASE, WAXY DISEASE. 

Latin Eq , Morbus Lardaceun—Jdem valent, Morbus Amyloidex, Morbus Cereu.i ; 
French Eq., Lardacle—Syn., Maladie Amylo'ide ; German Eq., Speckige oder 
Amylolde oder Wachsartige Degeneration; Italian Eq., Z/arrffflcco.— Syn., Malattia 
Amiloidea. 

Definition. — A lesion in which the normal textural elements of many organs- 
and tissues are transformed into, or infiltrated with, a peculiar substance, sug- 
gesting, on the one hand, an alliance (in some respects only) with the_ chemical 
characters of amyloid compounds, and, on the other hand, with albuminous sub- 
stances similar to those which pervade the tissues of fcetal life. 



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130 TOPICS RELATIVE TO PATHOLOGY. 

Pathology. — The London College of Physicians no longer regards this 
lesion as a degeneration, but classes it with other local lesions as a substantive 
disease. 

Professor Virchow, of Berlin, was the first to collect the facts regarding 
this peculiar form of disease, and to put them prominently forward. He 
proved the frequent occurrence in the animal economy of a degeneration, 
distinguished by the production of the peculiar substance to be described, 
which gradually takes the place of normal elements in the tissues so diseased. 
But Drs. Gairdner and Sanders, of Edinburgh, had anticipated many of the 
■ views and descriptions of the Berlin Professor, and, quite independently of 
Virchow, they initiated in this country the first steps in the elucidation of 
this very remarkable disease. They showed that the waxy condition of the 
liver and kidney was due to the same change as that which was seen to take 
place in the spleen. These valuable communications were made to the Phys- 
iological Society of Edinburgh ; and an account of them may be read in the 
Edinburgh Monthly Journal of Medical Science for Feb., 1854, p. 186, and also 
in May of the same year. Notwithstanding these researches, and those of 
Drs. Harris, Aldridge, and others in this country, we have much still to learn 
regarding (1.) The conditions under which this disease occurs ; (2.) The 
forms in which it exists ; and (3.) The symptoms of the lesion. 

This disease or degeneration has been long known by a variety of names. 
For many years the morbid anatomist has been familiar with a "bacon-like" 
or "lardaceous" infiltration of several solid organs of the body, and especially 
Xii the spleen and the liver. Portal and Abercrombie described the morbid 
condition in the liver as a " lardaceous degeneration ; " and Hodgkin and Bright 
described the same disease as an " albuminous infiltration." In 1842 Rokitan- 
sky was the first to give a clear account, and to describe in detail the " lar- 
daceous" infiltration of the kidney with an "albuminous" transparent sub- 
stance. The lesion so described constitutes his eighth form of " Bright's disease." 
But Rokitansky made no chemical examination of the infiltrated material. 
He simply assumed, from its general appearance, that it was of an albumi- 
nous nature, and he rightly recognized its pathogenetic relations to certain 
cachexias. Budd has described the disease as "scrofulous enlargement of the 
liver." Oppolzer and Schrant have described the lesion by the name of 
"colloid," and Baron by the name of " carnification." The pathologists of 
this country have hitherto described organs so diseased under the term of 
"waxy degeneration." 

Such are the names, derived from appearances generally, under which the 
peculiar disease has been described before microscopic examination demon- 
strated the condition of the structures implicated. 

Chemistry and micro-chemical investigations have modified the views 
regarding the nature of the disease, and now and then have led to modifica- 
tions in the nomenclature. Under this kind of inquisitive investigation it 
has been described (1.) By Virchow under the name of "animal amyloid". 
he believing, from the behavior of the transformed substance with iodine 
:and sulphuric acid, that the substance must be classified with the vegetable 
carbo-hydrogens — cellulose and starch. (2.) Meckel retains the name of 
•"lardaceous" or "cholesterin disease," believing that the essential character 
■of the degeneration consists in the development of a peculiar fatty or larda- 
ceous matter, of the nature of cholesterin. (3.) The more extended and 
•definite examinations by Friedreich and Kekul6 have shown that the sub- 
.stance of the purest amyloid degeneration more closely resembles the albumi- 
nous principles than any other substance we know of; and (4.) Schmidt has 
arrived at the same conclusion. The question, therefore, is not yet defini- 
tively settled as to the exact nature of the substance into which the tissues 
are transformed, but the weight of evidence points to its being albumen in 
.some form ; and the albuminoid deposits in the spleen of children, so well 



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NATURE OP LARDACEOUS DISEASE. 131 

described by Dr. Jenner, must be classed as examples of this disease, and 
probably also the special lesions in rickets. 

Investigations relating to lardaceous disease have taken especially three 
directions. Pathologists have endeavored — 

(1.) To trace the extension of the process of disease or degeneration 
throughout various tissues and organs of the body. 

(2.) To determine the essential nature of the material into which the tissue 
is converted. 

(3:) To determine the conditions under which the disease is brought about. 

Virchow first stated that the large Malpighian sacculi in the spleen (which, 
in some instances, looked like boiled grains of sago) were sometimes com- 
posed of a substance which gave the chemical reactions of cellulose, as seen 
in plants. Cellulose and starch are both vegetable constituents — "isomeria" 
forms of some common material ; and what gave special interest to the obser- 
vation of Virchow was the discovery that cellulose is also an element in the 
covering or skin of the "Tunicata" — a genus of acephalous mollusca — and 
therefore not a constituent of only vegetable organization. Dr. Robert 
McDonnell, of Dublin, has also shown that the bloodvessels of the foetus, at a 
certain stage of development, are of the same albuminoid matter. 

This discovery of cellulose in animal tissue induced Virchow to look for it 
or its analogue — namely, " starch" — in the human subject. He recognized it 
in the corpora amylacea of the brain. These contain a substance chemically 
related to starch or cellulose ; and these bodies were first seen and named by 
Purkinje, who gave them the name they have, not on account of chemical 
characters, but because he observed them to be laminated like starch. Of 
these corpora amylacea there are two kinds, nam'ely, — (1.) Mineral bodies 
with concentric circles more or less soluble in mineral acids ; (2.) Others 
which assume a blue tint with iodine, and a violet color on the subsequent 
addition of sulphuric acid. The relations of these two kinds to each other 
are still unknown. The first are the calcareous particles known as brain- 
sand ; and both were at first described under the name of " corpora amylacea " 
by Virchow, which has led to some confusion. The term ought to be restricted 
to those bodies which, by physical and chemical characters, are assimilated 
to starch. The mineral bodies erroneously described as corpora amylacea are 
chiefly found in the cysts of the choroid plexus and in the pineal gland. On 
the other hand, the starch-like bodies have been found by Virchow, Rokitan- 
sky, Scherer, Kolliker, Busk, and other observers, in the ependyma of the 
ventricles, the septum lucidwn, the fornix, the auditory and the optic nerves, 
and also in the prostatic ducts. Concentric lamination of these bodies is not 
always present ; nor is the reaction with iodine and sulphuric acid constant. 
For these reasons Virchow began to examine those organs whose morbid state 
was described by the names already mentioned as having been given to the 
fatty or waxy spleen. He applied solutions of nitric acid, which, when hot, 
gave a yellow hue ; he applied caustic ammonia, which gave a brown color ; 
and from behavior with reagents generally, he concluded that the substance 
was " ALBUMINOID " iu its nature. Iodine and sulphuric acid were subse- 
quently tried. Iodine alone gave a strong yellow-red ; sulphuric acid being 
added, developed a blue color, passing into a strong violet hue. An excess 
of acid destroyed the violet hue, causing a dark brown-red color, passing into 
yellow. Meckel, subsequently to these observations of Virchow, came to_ the 
conclusion that there were four forms 'of this waxy material — that the basis of 
them all was a peculiar fat allied to cholesterin rather than to starch — that 
various saponaceous products are formed, ending in the development of choles- 
terin ; and although he did not sustain his statement by anything like suf- 
ficient proof, he made the important discovery that it was the system of small 
arteries and capillaries which first suffered in this disease. 

The inquiry into the chemical nature of the lesion becomes still more inter- 

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132 TOPICS EELATIVE TO PATHOLOGY, 

esting when connected with the observations and discoveries of Bernard, Pavy, 
and others, on the "sugar-producing" functions of the liver, and on the 
material so formed, which may be separated by chemical processes, and has 
been recently shown by Dr. Kobert McDonnell to be a substance which enters 
largely into the constitution of most of the tissues of the embryo (Proceed. 
Royal Society, vol. xii, p. 476). The results of these inquiries bring the 
" starchy substances " of animals in very close physiological alliance, and also 
in alliance with morbid results. The material so found has been called indif- 
ferently " glycogene," " amyloid matter," " zoo-arnyline," or " animal-starch." 
It owes it origin, not to any direct function of the organ, but its formation 
seems to take place almost immediately upon contact with albuminous mat- 
ter, when this remarkable product is the result, and which may be obtained 
as a white powder. It seems capable of being produced in greatest abun- 
dance by the hepatic tissue ; but its formation may proceed at any part of 
the vascular capillary system. If, therefore, it is thus formed normally, it 
may also be formed, retained, or transformed in a morbid way. In diabetes 
we have an instance of the transformation of the product into sugar at the ex- 
pense of the tissues at large ; and which sugar is so discharged by the urine. 

The disease now under consderation has thus had various names to denote 
its presumed chemical nature, namely, — (1.) Cellulose degeneration; (2.) 
Amyloid degeneration; (3.) Cholesterin disease; and now (4.) Albuminoid 
degeneration. 

The analysis of the pure matter is very defective. Such as it is, it shows 
the substance to be albuminoid, and combined with nitrogen rather than 
starch; and those who describe the reaction of cellulose and starch with iodine 
and sulphuric acid, seem only to agree with each other in giving singularly 
diversified descriptions of color, which, perhaps, to those familiar with the 
writings of the late Dr. George Wilson, on color-blindness, may be accounted 
for. Such diversity may be explained in some measure, also, by the fact that 
the degree of concentration of the reagents materially concerns the results ; 
for, as Virchoweorrectly observes, the blue coloration is only got after a con- 
siderable period, and in practiced hands, and it may pass from a bright pur- 
ple to a very blue or even black color ; in fact, the blue-black color is an 
error resulting from the decomposition of the iodine solution, by excess of sul- 
phuric acid, throwing down the iodine, which blackens the tissue. Neverthe- 
less, the action of iodine solution on the lardaceous tissue is peculiar and 
definite, independently of a blue color. It is of the nature of a chemical 
reaction. 

The appearance of a chemical reaction, which gives a hue different from 
the mere dyeing with the iodine, and which suddenly deepens in tone, from 
the moment it begins to take eifect, to a deep brown-red color, is sufladently 
characteristic. When this takes place with the solution of iodine alone, it 
distinguishes at once the substance from cellulose and cholesterin. 

By way of chemical analysis very trustworthy results seem to have been 
arrived at by Friedreich and Kekule. On submitting the white amyloid 
matter to ultimate analysis, thev obtained the following composition in 
equivalents per cent. (Med.-Chir. Review, 1861, p. 59). 

Amyloid, =53.58 7.0 15.04 

But the composition of albumen, according to Dumas and Cahours, Lieber- 
kiihn, and Ruling, is as follows : 

*^- H- N. 

Albumen, ....=( 53 5 .... 7.1 .... 158 

7.2 



Dumas and Cahours, ) 53.4 
^53 5 

LieberkiihD, . . . 53.5 
Riiling, 53.8 



73 
7.0 
7.1 



15.7 
157 
15fi 
15.5 



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ANATOMICAL CHARACTERS OF LARDACEOUS DISEASE. 133 

These results show an almost perfect chemical identity between albumen 
and the morbid substance found in the so-called waxy or lardaceous spleen ; 
and demonstrate that the waxy disease, in the spleen, at least, is due to a 
peculiarly modified albuminous material, and not to starch. On the other 
hand, the chemistry of the corpuscular variety of the corpora amylaeea occur- 
ring as a deposit in various parts — e. g., in the brain, the prostate, and the 
ependyma of the ventricles — shows a reaction almost identical with starch. 
The corpuscles also have concentric laminse, and, according to some, resemble 
starch-granules when polarized. As regards the corpuscles of the prostate, 
sugar has been chemically produced from them, and demonstrated by Trom- 
mer's test. 

Many of these corpuscular varieties of amylaceous bodies are no doubt of 
the same nature as starch ; and therefore the direction which inquiry ought 
now to take will be to determine "whether or not there is any chemical 
affinity on the part of the formless matter of lardaceous disease with the cor- 
puscular variety of the amylaceous concretions?" Such an affinity has been 
assumed hitherto; but, so far as observation has gone, the evidence of any 
affinity seems to be getting less and less. On the other hand, the modifying 
effects of admixture and of growth are very remarkable as regards these pros- 
tatic concretions. Some of them iodine will not color blue, not even after 
sulphuric acid has been added ; and as growth proceeds, any starchy matter 
they contain gradually disappears. Many admixtures of organic and inor- 
ganic substances give various shades of color ; and the yellow-brown colored 
deposits failed to give forth sugar to Paulizky's attempts. 

General Characters and Anatomical Description o^ Tissues affected with 
Lardaceous Disease. — The cut surface of an organ so affected has a semi- 
transparent appearance. It feels like a. piece of soft wax, or of wax and laM 
combined (Wilks). It cuts into portions of the most regular shape, with 
sharp angles and smooth surfaces; and the thinnest possible slices may be 
removed by a sharp knife for microscopical examination without any special 
preparartion. The tissue is abnormally translucent. Water, alcohol, and 
acids do not produce any change upon the transformed parts, which may be 
kept for a length of time without decomposition. The organs affected are 
increased in volume, in solidity, and in weight, absolute and specific. Anaemia 
is predominant ; but the color of blood or of tissue shines through the semi- 
transparent morbid substance. 

Lardaceous disease is generally widely diffiised ; so much so, that a consti- 
tutional state of ill-health seems associated with its production ; and in cases 
preceded by a local disease, such as caries of a bone, the lesion may be found 
in the adjacent lymphatic glands only (Billroth). This is the earliest 
appearance of the disease yet recognized. 

The small vessels of the tissue — the more minute arteries in particular — 
are, as a rule, the first structures attacked. The coats of the arteries become 
granular and thickened, apparently by exaggeration of their transverse fibres, 
and at last pellucid, transparent, and hyaline. Their calibre is reduced, and 
their cut section remains patulous. 

It is the transverse fibres of the middle or muscular coat of the vessels 
which first change. Each fibre-cell becomes a compact hyaline, pellucid, 
transparent particle, with an indistinct outline, and all the tissue involved 
becomes at last uniform, clear, and transparent. The diseased artery looks 
like a compact, homogeneous, silvery cord or thread, of a clear and glassy 
appearance, with a lustre like molten glass without polish, or like rough ice. 
This colorless, hyaline, diseased tissue is very tough, but not hard nor brittle, 
like the calcareous degenerate parts. All degenerations tend to obscure the 
original texture, by making it more opaque. This disease, on the contrary, 
renders the affected tissue more transparent and pellucid. The specific cells 
of the functional parenchyma, when the disease affects a solid organ like the 

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134 TOPICS RELATIVE TO PATHOLOST. 

liver or kidney, next undergo the change, which finally spreads to the nutrient 
vessels amongst the connective tissue. According to Dr. Dickenson, the mor- 
bid matter penetrates the coats of the minute vessels, and gradually works its 
way into the surrounding tissue; and the changes which thenceforth result 
vary according to the organ' affected. In the solid viscera the lardaceous 
material remains about the vessels, and fills the interstices of the texture. 
Thus, the organs so affected, especially the liver and spleen, increase in size, 
becoming hard, gray, and semitransparent, as if uniformly infiltrated with 
wax. The kidneys, suprarenal capsules, and lymphatic glands are all apt 
to assume the same firmness and wax-like transluceucy. In the spleen the 
deposit often exaggerates the Malpighian sacculi, till they are larger even 
than grains of boiled sago — more like tapioca, I have seen them in many 
instances. In the mucous membranes of the small intestines the vessels are 
similarly altered in appearance ; but Dr. Dickenson believes that the exuda- 
tion, instead of being retained, is passed oflT by diarrhoea ; or, if the stomach is 
afiected, by vomiting. 

When a solution of iodine is brought in contact with the afiected part, a 
very deep violet-red color is produced. This deep-red color seems to be alone 
a sufficiently characteristic test of the existence of the disease, especially when 
in a few seconds the color increases iu depth , from the moment it begins to 
take effect. The morbid material seems to have a strong affinity for the 
reagent, " absorbing it readily, holding it tenaciously, and assuming its full 
color," while the healthy parts take only a faint and superficial yellow tinge. 
Hence the contrast which the deep reddish-brown of the morbid parts pre- 
sents, against the uniformly faint yellow of the normal tissue in which it may 
be placed (Dickenson). It is of the nature of a chemical reaction which 
ensues between the iodine solution and the morbidly degenerate part. The 
best test-solution is composed as follows : Twelve grains of Iodine is to be dis- 
solved with twenty-four grains of Iodide of Potassium, and mixed with three 
ounces of Water. Such a test-solution ought always to be at hand in the 
dead-house, or on making a post-mortem examination anywhere. 

Elepients of Tissue in which lardaceous Disease has been demonstrated. 

I. Nervous System : Ligamentum spinale cochlese : atrophied parts of brain 
and spinal cord : gelatinous softening, and tumors. 

• 2. Spleen : Cells of the Malpighian sacculi and pulp : thickened walls of the . 
arteries in all stages : the trabeculse. 

3. Liver: The hepatic cells and intralobular vessels, and intercellular 
tissue. 

4. Kidneys: Malpighian tufts and afferent vessels, the walls of which 
become enormously thickened : areolar tissue in the vicinity of the papillaiy 
ducts. 

5. Muscular tissue of the heart and the uterus. 

6. Bloodvessels of the villi and mucous membrane of the alimentary canal. 

7. Osseous tissue. 

8. Lymphatic glands. 

9. Old deposits in serous membranes, having lost their fibrous character, 
becoming dense, more vascular, and semitransparent, undergo this metamor- 
phosis (Gaiedner). 

10. Tubercle also becomes lardaceous (Gaiedner). 

II. The cancerous nodules in a waxy liver also become lardaceous 
(Gairdner). 

12. In some cases of inflammation with exudation on the mucous membrane, 
the exudation has become lardaceous (Virchow). 

13. The fibrin of a hsematocele (Friedreich). 

The extensive range of organs in which this remarkable lesion has now been 
demonstrated clearly shows that it cannot be regarded as merely of local im- 
portance. Its occurrence seems rather to point to some general pathological 

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RESULTS OF LAKDACEOUS DISEASE. 135 

state of which the lesion is the expression. In the first instance it is found 
more particularly affecting the functional capillaries of the most important 
organs of the body — e. g., the kidney, the liver, the spleen, the intestines, as 
well as the minute arteries of nutrition of those organs, and of the pia mater, 
bone, and lymphatic glands. The results of such a disease must therefore be 
sooner or later destructive, — (1.) To the function of the invaded organ ; ■ (2.) 
To its nutrition ; and we can only arrive at a correct pathology of this degen- 
eration by a close observation of the circumstances, condition, relations, and 
symptoms under which the lesion manifests itself These must be studied 
especially in relation to the functional or physiological anatomy of the organs 
implicated. As yet the lesion has been recognized with certainty only in the 
dead-house. There it has been found associated with certain diseased states ; 
and all the cases agree in this particular, namely, that the constitution of the 
patients has been broken up by ill health (cachexia) of some considerable 
duration before death. So it has been amongst the soldiers dissected at Fort 
Pitt and atlSTetley ; and the following statement is a summary of diseased 
conditions, in the order which furnishes the greatest number of cases of larda- 
ceous diseases : 

Diseased States with which Lardaceous Disease has been found associa- 
ted, or upon which it is engrafted. 

1. Diseases of the hones, especially caries and necrosis in scrofulous subjects. 
Rickets also leads to the amyloid liver and spleen, as observed by Glisson, Por- 
tal, Eokitansky, Lambe, Lceschner, Frerichs, arid Jenner. 

2. Syphilis, especially in its ulcerative forms, the cachexia having been 
prolonged. Syphilitic children have been the subject of it when newly born. 

3. The malarious cachexia, especially intermittent fever. 

4. Mercurial cachexia and marasmus. 

5. Pulmonary and intestinal forms of tubercle. 

6. Albuminuria and anasarca. 

7. Diseases of large arteries. 

It has been more recently urged by Dr. Dickenson that the degeneration is 
always the result of extensive purulent formation of long duration. He 
believes that its mode of origin has to do with the removal of alkalies from 
the system ; which long-continued suppurations' tend to do, leaving a relative 
increase of fibrin. Five-sixths of the cases recorded by him were connected 
with suppuration. Hence he proposes the term depurative infiltration as sig- 
nificant of its pathology. Pus is an albuminous fluid rich in alkaline matter, 
containing about 1 per cent, of alkaline and earthy salts, in the proportion of 
ten of alkaline to one of earthy salts. Next to suppuration, albmninuria, when 
connected with nephritis, is the most frequent antecedent of lardaceous disease ; 
the long-continued discharge of albumen carrying alkali with it. 

As to the origin of the lesion or degeneration, Frerichs has propounded two 
questions, namely, — (1.) Is the lesion due to deposits from the blood of the 
albuminoid matter in some primordial form, and which is generated in the; 
blood in consequence of a local disease, such as caries of the bones or other' 
suppurative processes ? (2.) Is the albuminoid matter developed locally in. 
the affected tissue by the transformation or degeneration of the tissue into. 
albuminous matter ? 

Arguments are put forward by Virchow and Frerichs to show that the lesion 
may be due to a deposit from the blood ; and Dr. W. H. Dickenson comes to 
the conclusion that the deposit essentially consists of an exudation of a pecu- 
liar material differing from the proper constituents of the body. He considers 
the Substance essentially fibrous; and so deposited in consequence of the 
absence of alkali necessary to hold it in solution. Hence he names it " de-al- 
-kalinized fibrin," and not a form of albumen. He believes it to be fibrin, 
rather than albumen, on account of the strong tendency it shows to undergo 
contraction after its deposition. It becomes converted into fibroid tissue as a 

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136 TOPICS RELATIVE TO PATHOLOGY. 

coagulum in the arachnoid or as vegetations on the valves of the heart. In 
certain cases also it is identical in appearance and reaction with the hyaline 
casts of the kidney tubes, believed to be fibrinous. Fibrin can be also con- 
verted into the lardaceous substance by removing the alkali it naturally con- 
tains, or only neutralizing it. Conversely, if potash or soda be added to the 
morbid matter, it ceases to give the characteristic reaction with iodine. It 
will not decompose the color of sulphate of indigo, as healthy tissues contain- 
ing alkali will do. Analysis of lardaceous livers show a diminution by one- 
fourth of alkaline salts, and the earthy salts exist in larger quantity than in 

health. ■ • x' i. 

But there is also undoubted evidence to show in some parts it is of the 
nature of a degeneration. For (1.) In cases where the lesion follows afiec- 
tions of the bones, the lymphatic glands adjoining the diseased bones are im- 
plicated before the kidneys, liver, or mucous membrane of the intestines. 
(2.) General causes of ill-health (cachexia), pointing to impoverished blood, 
are in operation, and organs situated in different parts of the body are simul- 
taneously affected. (3.) The. fibrin of the blood itself has been observed to 
undergo the degeneration ; for Friedreich found a substance which gave the 
amyloid reaction with iodine in the old fibrinous layer of the sac of a hsema- 
tocele. 

In this remarkable lesion or degeneration an acquaintance with a new fact 
in pathology must be recognized — i. e., since 1854 — associating itself with 
grave constitutional disease, and distinguished from every other morbid condi- 
tion hitherto known, by the physical, chemical, and physiological characters 
just described. 

The Clinical History of Lardaceous Disease is,remarkably deficient. The 
effect of the degeneration is to interfere with function of organs and nutrition 
of parts ; and the injurious effects are the more marked as the lesion extends 
through many important organs. For example, hepatic cells cease to take 
part in the formation of sugar or the secretion of bile. Bloodvessels lose their 
power of transmitting fluid through their walls, and become impervious as to 
their canals. Hence those who suffer from lardaceous disease have an appear- 
ance of general ill-health, denoted by paleness of the surface, by symptoms of 
anaemia, hydrsemia, or by leuka3mic affections of the blood ; and the more so as 
the constitution is enfeebled by such morbid processes as suppurative ulcera- 
tion of bones, syphilis, tuberculosis, albuminuria, or malaria. The sequence 
in which the different organs degenerate is uncertain. In most cases of caries 
and necrosis the kidneys seem to be first attacked after the lymphatic glands. 
In cases of intermittent fever, it is usually the spleen which is first affected ; 
and generally it seems rare to find several or all the organs affected to the 
same extent. 

Signs or Symptoms associated with this Degeneration discoverable dur- 
ing Life. — On these points data are wanting upon which to found any state- 
ment. The pathological change is of so recent discovery, that well-recorded 
cases, terminating in death, with verification of the symptoms by post-mortem 
inspections, are very few indeed. There is no subject, therefore, more full of 
interest, or one more likely to repay close observation and well-directed patho- 
logical inquiry, than the diagnosis of lardaceous degeneration. Cases in hos- 
pital ought to be most carefully noted, and especially such ambiguous cases 
' as those where marasmus, ansemia, or dropsy are primary symptoms, and 
which are not to be accounted for even after the blood has been examined mi- 
croscopically during life, and the condition of the liver, heart, spleen, and 
lymph-glands carefully inquired into, without evincing signs of disease. In a 
remarkable ease recorded by Friedreich and Kekul6, and quoted in the 
Medico- Chirurgical Review for October, 1860, diarrhoea and vomiting were 
of frequent occurrence, with a systolic murmur of the heart, and high-col- 
ored and albuminous urine, with a specific gravity of 1.019. The patient, a 

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DEFINITION AND PATHOLOGY OF CYSTS. 137 

female, after suifering from tertian ague for twelve months, .became dropsical 
and emaciated. The intestines throughout, the stomach, the colon, the jeju- 
num, and especially the capillary vessels of its villi, were affected, as well as 
the vessels of the kidneys. The urine should be watched as to albumen, or 
deposits, and its amount in relation to body-weight should be recorded. 
When albumen appears, it goes on gradually increasing ; and hyaline gases 
increase with the increase of albumen. 

Dr. Stewart, of Edinburgh, records twenty cases and nine dissections in 
cases of Bright's disease, where he considered lardaeeous disease to have been 
present (Edinburgh Medical Journal for February, 1861). He records that 
large quantities of urine were passed in the early stage of supposed waxy de- 
generation, and of a specific gravity from 1.005 to 1.015. In all the cases 
there was a striking general correspondence in the other symptoms ; and Dr. 
Stewart thinks that from this similarity of symptoms, and from other consid- 
erations, he is warranted in believing that lardaeeous disease existed in the 
eleven cases that did not die. The history of all Dr. Stewart's cases is markedly 
different from that of the fatty kidney which Dr. Bright figured in his first 
plate, and illustrated in his first case. Almost all of the cases were associated 
with long-continued wasting disease; and it has been long known that the 
form of renal affection accompanying phthisis, syphilis, and other wasting 
maladies, is this lardaeeous disease. Of the twenty cases related by Dr. 
Stewart, six were associated with phthisis, six with syphilis, two with caries, 
two with intemperance, one with cancer, one with chronic rheumatism, and 
two with no particular disease. 

The lesion is much more common than is generally supposed. It has been 
observed very frequently amongst the soldiers who have been dissected at the 
Military Hospital for Invalids, formerly at Fort Pitt, and now at Netley. The 
microscope and iodine test can alone determine its presence; and without 
microscopic examination the absence of the degeneration cannot be deter- 
mined. For a detailed account of lardaeeous disease in the various organs, 
see the descriptions given under Local Diseases. 



CYST. 
Latin Eq., Cystis; PRENcn Eq., Kyste ; German Eq , Cyste ; Italian Eq., Ciste. 

Definition. — A cyst, sac, or hag (to the exclusion of capsules or sheaths forming 
round foreign bodies, extravasations, or parasites), filled with some substance 
which may be regarded as entirely, or for the most part, its product, whether as a 
secretion or as an endogenous growth. 

Pathology. — Many theories have been put forward to explain the forma- 
tion of cysts; but no single hypothesis has yet been sufficient to account for 
their formation in all situations where they have been found. It has been 
extensively taught that the structure of a cyst consists of an excessive augmen- 
tation of volume of the alveoli of the areolar tissue, composed of condensed 
and modified filamentous tissue. Bichat urged many objections to this view, 
and held that cysts, being in many respects analogous to serous sacs, they 
ought to have the same origin. He held that cyst-growths were aberrant 
forms resulting from unnatural growth of germs in and amongst areolar tissue, 
and that the contents increased with the enlargement of the cyst by growth. 
Rokitansky subsequently followed very much the idea of Bichat, regarding 
the cyst, from its organization and secretory function, as a definite hollow 
■structure, whose essential rudiment is a definite functional elementary germ_ or 
granule. But there are no doubt some cyst formations due to the dilatation 
and growth of natural ducts, sacculi, or follicles, as well as others which form 
by the enlargement and fusion of areolar spaces in connective tissue. 

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138 



TOPICS RELATIVE TO PATHOLOGY. 



Thus there are three modes in which cysts may be formed, namely : 
(1.) Cysts ^vhich are a substantive new growth, having a distinct elementary 
groundwork, derived from cells or the nuclei of cells, pursuing a morbid course 
of growth from their origin, and reaching an enormous development. 



Fig. 11. 







(2.) Cysts which are formed by obstruction, dilatation, and growth of natural 
ducts or sacculi. Examples of such cyst-formations are seen in sebaceous or 
epidermal cysts formed from enlarged hair follicles, and the cysts formed by 
dilated mucous tubes ; also certain cysts, containing milk, from enlarged jsarts 
of lactiferous tubes; ovarian cysts from overgrown Graetian vesicles; and 
lastly, cysts formed froni dilated bloodvessels shut off from the main stream. 

(3.) Cysts formed by enlargement and fusion of the areolar spaces in con- 
nective tissue. The tissue of the wall of such cysts becomes condensed, and 
the inner surface secretes fluid like a serous sac. 

Although the observations of Rokitansky and Simon point to the growth 
of cysts in the kidney from the original primary cell elements, yet the obser- 
vations of Drs. Gairdner and George Johnson equally explain their forma- 
tion by local obstruction of viriniferous tubules, and their dilatation into cysts 
above or between the points of obstruction. But whatever may be the source 
of their formation, Ave have yet to learn, as JMr. Paget specially notes, why 
they tend continually to grow. 

The Figs. 11 aud 12 are Rokitansky's representations of the minute struc- 
ture of cysts of the kidney. They represent "nests" of delicate vesicles, 
from a size just visible by ild to jth lens to the size of a millet-seed, imbedded 
in a red-gray whitish substance. 

They represent proliferous cyst-formations from the cortical substance of the 
kidney, as a sequel to Bright's disease. The two figures illustrate well Roki- 
tansky's history of proliferous cyst-development, and at the same time what 
he understands by the often-occurring expression, "alveolar type or arrange- 
ment." 



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CLASSIFICATION OF CYSTS. 



139 



Fig. r2. 







lu Fig. 11 we have the cyst in all its phases, a is a simple cyst, arising out 
of the expansion of the elementary granule, first into the nucleus, from this 
into the cell, and progressively into the cyst. But it has remained barren, 
and contains only a diaphanous viscid serum within a simple cyst-membrane. 
h ' represents a parent 
C5'st, the early history of 
which accords with that 
of the barren cyst ; within 
it, however, new granules 
have formed, and gradu- 
all}' became developed 
into vesicles or cysts con- 
taining other nuclei, un- 
til the parent cyst has 
become replete with 
them, and, from being 
spherical, they are ren- 
dered polyhedrieal by 
nmtual compression. In 
an adjoining parent cyst, 
many of the filial cysts 
have remained barren ; 
others contain nuclei in 
the act of splitting, c, c, 

c, c, represent another 
form of develo]3nient of the parent Cj'st. Here, again, the parent cyst has 
gone through the same phases, from the elementary granule upwards. But, 
as the cell dilates into the cyst, a granule forms centrally to the latter and 
expands into a filial cyst, centrally to which a third granule opens out in the 
same manner; and so on. These intracystic cysts in their dilatation ulti- 
mately close upon the parent cyst, forming secondary, tertiary, and ulterior 
layers, to which an external fibrous layer is generally added out of the sur- 
rounding blastema. Or this fibrous coat occurs in the alveolar shape. Fig. 
11 affords several examjjles of this. It is, however, better seen in 

Fig. 12 — Where a is the fibrous sheath in progress of development out of 

d, the elongated and caudate nuclei coursing around the parent cyst or aggre- 
gation of parent cysts. They eventually break up into the requisite fibres. 
e is to represent the point-molecule, within an amorphous blastema, out of 
which the nuclei (b) form. They are at first spherical, afterwards elongated, 
and ultimately broken into fibrillation. TJiis constitutes what the author 
designates as the " alveolar type or arrangement." 

Kokitansky teaches that the nucleus grows to be the cyst, whether it be 
simple or barren ; and that the outside layers of the cyst-walls, if they are 
complex and thick, are made uj) of endogenous growths, of nuclei, of cells, or 
of any other structures. 

Thus, a classification of cysts has been conveniently arranged into 

(a.) Simple or barren; and into 

(b.) Compound or j'jroliferou.i. 

Simple or barren cysts contain fluid or organized matter ; comjjound or 
proliferous cysts contain variously organized bodies (Facet). 

The simple or barren cysts may occur singly or many together (when they 
are called "multiple cysts"), and contain a fluid like that of a serous sac 
(mammary cysts, choroid plexus cysts, synovial cysts). Some are full of 
blood, or colloid stuff (glue-like ), or other peculiar or abnormal fluid. Others 
(transitional between barren and proliferous cysts) contain specific secretions, 
such as milk, semen, mucus, saliva ; and they are thus named, according to 



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140 TOPICS RELATIVE TO PATHOLOGY. 

contents, as lactiferous, seminal, mucous, salivary, Qolloid, sanguineous, synovial, 
serous. 

The simple or barren cysts contain one or other of the following materials : 

(a.) Gaseous cysts (examples o{ pneumatoses, see p. 118, ante) are mentioned 
by Mr. Paget, on the authority of Hunter, Jenner, and Cavendish, and the 
preparation is preserved in the Museum of the College of Surgeons, No. 153-4 ; 
but beyond the description of Plate xxxvii in Hunter's Works, vol. iv, p. 
98, nothing is known concerning such gaseous cysts. 

(6.) Serous cysts, or hygromata, are the most frequently seen. They include 
nearly all which have thin liquid or honey-like contents, of a yellow or brown 
color. They are most frequently found near the secreting or vascular glands ; 
and there is scarcely a part of the body in which they may not be found. So 
common are they in and amongst gland-structures, that they are believed to 
arise from the same germinal elements of membranes that furnish the per- 
petual growth of glandular or secreting elements. Thus, in such sites they 
are held as examples of perverted epithelial or gland-cells. But they are no 
doubt independent of such origin, as in bones, connective tissues, muscles, 
nerves, and fibrous tumors, where their origin is quite independent of gland- 
cells. So complicated are the contents of some cysts, as in bone, that perfect 
ciliated epithelium has been observed in them (Wedl). 

Serous cysts occur chiefly in the neck, the mammary gland, and the gums. 
In the neck they are sometimes described as " hydroceles of the neck." They 
may be single or multiple to the extent of hundreds, having many cavities, 
either separate or communicating. A case of this description proved fatal at 
Netley Hospital in November, 1870. The patient was a young soldier, only 
eighteen years of age, and of five years' service. The left side of the neck 
was enlarged from many cysts, which had been opened into during life, and 
which, at death, were in a state of active suppuration, so that the original 
connection of the cysts was not traceable. On the right side of the neck a 
smooth tumor, about the size of a turkey's egg, occupied the lateral region, 
extending beneath the platysma myoides, and lying between the fibres of the 
deep muscles of the neck, from an inch and a half below the ear to an inch 
and a half above the clavicle. Commencing small cysts were seen posterior 
to the tissue of the left tonsil, and the pressure of the diseased parts, especially 
from the left side, caused extensive cedema of the pharyngeal and laryngeal 
mucous membrane. The cysts had no connection either with the thyroid or 
lymphatic glands of the neck. Another mass of cystic growths occupied the 
entire pelvis, and was apparently divided into four large lobules. These 
growths pushed the bladder over to the right side, pressing upon it anteriorly, 
and from the left. There was also another development of large cysts in the 
soft parts about the left hip, and upper part of thigh, but the joint was in no 
way implicated. Some of the cysts had been opened in the thigh by a trocar, 
and had commenced to suppurate. The cysts, which were entire, contained 
clear serous fluid, highly albuminous, of a straw color, and having a specific 
gravity of 1.017. The fluid was frequently examined during life, several pints 
having been removed from time to time, but neither during life nor after 
death were any evidences of parasitic development (such as echinococcus) 
discoverable. 

The cysts were obviously developed in and amongst the areolar tissue of 
the neck, pelvis, and thigh ; but the origin of the cysts is extremely obscure. 
It is most probable they had their origin in the corpuscular elements of the 
connective tissue or juice canal system, which permeates that tissue. The 
subject of this cystic disease had been considered to be suffering from scrofula, 
and had been 129 days in hospital at Gibraltar. The exciting cause of the 
swellings was attributed to sleeping in a wet tent, when encamped with his 
regiment at "Windmill Hill. Thence he was invalided to Netley, where the 
cystic nature of the tumors in the neck and hip was recognized. On admis- 

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EXAMPLES OF SEllOUS CYSTS. 141 

sion, there was enormous swelling of the left neck from the ear to the clavicle, 
and from the region of the left parotid gland to th^ Ugamentum niwlue. Several 
small openings existed, from which a thin watery discharge exuded. He 
complained of pains in the left hip, simulating rheumatism, accompanied with 
a moderate general swelling of the joint. Respiration sounds were normal. 
He was a spare ansemic lad, badly nourished, and of unhealthy aspect. For 
two months after admission to Netley, the swelling in the neck progressively 
increased in size, and the patient continued to lose flesh, and became more 
and more cachectic. A puncture was made with a small trocar, in two places, 
by Staff Surgeon-Major Mackinnon, C. B., and serous fluid, to the extent of 
six ounces, escaped. The fluid, however, accumulated again very rapidly ; 
and ten days later, about half a pint of blood-serum was removed and care- 
fully examined for parasite developments, but with a negative result. At 
this time swelling about the hip-joint was observed. It was of a uniformly 
rounded contour; and the circumference of the upper part of the left thigh 
was five inches in excess of the corresponding part of the opposite limb (right 
side, 15^ inches ; left side, 20^). There was much tenderness on pressure 
over the joint ; but pressure on the condyles of the femur, in an upward direc- 
tion, did not cause pain in the hip-joint, neither was there lengthening or 
shortening of the limb. Five days later, sixteen ounces of fluid were evacua- 
ted from the facial tumor, and eleven ounces on the following day. After 
another five days, Mr. Mackinnon made an incision over a tumor at the lower 
part of the neck, and exposed a dense glistening membrane — the wall of 
another cyst — from which serous fluid escaped as from the others. Five days 
afterwards, another tumor was observed on the right side of the neck, rounded, 
smooth, and fluctuating, and this gradually continued to increase till death. 
It was left unopened. The openings by trocar, into the cysts in the left side 
of the neck, led to a depth of several inches ; and two of the cysts communi- 
cated ; two others opened into were isolated. Much pain was subsequently 
experienced in the region of the left hip, and in eighteen days the circumfer- 
ence of the thigh had increased three inches. An opening was now made by 
trocar into one of the swellings over the hip, and a pint of fluid evacuated : 
five days later, twenty ounces more escaped. The fluid was of the consistence 
of very thin arrowroot, and with a tendency to stringiness between the fingers, 
consisting almost entirely of an albuminous solution, coagulating into a solid 
white mass on boiling. Soon after, a large tumor, firm and round, containing 
fluid, was detected in the pubic region, giving a sensation to the hand similar 
to a contracted uterus. It was tender on pressure, and much pain was expe- 
rienced on micturition. The excessive daily discharges from the several open- 
ings and cyst surfaces, combined with the acute pain in the hip, and the onset 
of laryngeal irritation from oedema and pressure on larynx and trachea, eventu- 
ally terminated fatally. 

In young children such serous cysts are often congenital (hyt/roma colli oys- 
tieum congenitum). Some are connected with the thyroid gland, others are 
transformations of vascular tumors, such as erectile vascular growths or nsevi 
(Paget). 

Cysts in or near the gums, with contents of a thick honey-like consistence, 
and generally sparkling with crystals of eholesterin, are usually found lying 
behind the reflection of the mucous membrane from the gum to the cheek. 
From their tough thick walls in that situation, they are apt to simulate dis- 
ease of the antrum. 

Cysts in the mammary gland are often due to dilated ducts, portions of 
which assume a cystic form. They may contain milk. Mr. Birkett records 
numerous cases of this kind, from one of which he evacuated ten pints of 
milk. Some contain the remains of milk, such as fat and epithelial scales ; 
or they may be filled with transparent watery fluid, uncoagulable. More 
commonly they contain serous fluid, pure or tinged with blood. They may 

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142 TOPICS RELATIVE TO PATH0L08Y. 

also originate (like those of the kidney) independently of the gland-tubes 
(BiEKETT, Paget). 

Mr. Paget lays down the general rule that the cysts which contain the 
simplest fluids, and which have the simplest walls, are apt to grow to the 
largest size. 

Synovial cysts acknowledge three methods of formation : (a.) From widen- 
ing of spaces in areolar tissue, forming, by condensation, bursse as the result 
of pressure ; (b.) Cystic transformation of cells inclosed in the fringe-like 
processes of the synovial membrane of the sheaths of tendons, such as those 
near the wrist-joint, forming ganglions, as they are called. They resemble 
the cysts of the choroid plexus, which grow from the villi at the margins of 
the plexus (Rokitansky). (c.) The mouths of subsynovial follicles, which 
normally open into the cavity of the joint, become obstructed, and the folli- 
cles undergo such dilatation as converts them into subsynovial cysts (GossB- 
LiN, quoted by Paget). Such synovial cysts vary as to contents, being some- 
times serous, gelatinous, or honey-like. 

Mucous cysts are formed in connection with simple mucous membranes, or 
ducts of mucous glands, such as those about the cervix uteri, giving rise to 
Nabothian cysts; or connected with Cowper's glands in the male, forming 
Cowperian cysts. Similar cysts form in connection with cutaneous follicles. 
Examined microscopically, such cysts contain epithelial scales, free fat, tables 
of cholesterin, crystals of triple phosphate, and small hairs in various pro- 
portions. 

Many abscesses projecting into the vagina have their origin in glands near 
the orifice (Baetholino), which become cystic (Paget). 

Mucous cysts are recorded also in the antrum ; in the mucous membrane of 
the stomach and other parts of the alimentary canal ; in the uterus ; in the 
posteriorwall of the trachea, forming cystic tumors lying between the trachea 
and oesophagus (Viechow) ; in the back of the epiglottis, and covering the 
upper orifice of the larynx (Dueham). 

Ranula is an analogous aflTection of the duct of the sublingual gland. 

Sanguineous cysts contain blood, and are probably the result of hemorrhage 
into the cavities of serous cysts, like the transformation of pericarditis into 
hemorrhagic pericarditis, or of a hydrocele into a hcematooele. Such blood-con- 
tents are generally coagulated or thick. Others have their origin in vascular 
ncevi. 

Oysts containing oil or fat are rare, except as the residue of fatty degenera- 
tion of other matters. Colloid cysts embrace cysts containing all those mor- 
bid materials described as "pellucid," "jelly-like," "flickering," "half-solid," 
"glue-like." Such material is common in the cysts of bronchoceles and in 
kidney cysts. The density of such contents varies from that of serum to that 
of a firm jelly, and in color it may be of any hue. 

The second kind of cysts are the proliferous or compound cysts, and are so 
named from the occurrence of secondary growths in the interior of the origi- 
nal cysts — cysts growing within cysts, or upon their walls, as in complex ova- 
rian cysts. These secondary growths may hang pendulous from the walls ; 
and immense proliferous power exists in ovarian cysts from Graefian vesicles. 
On this subject the student must consult Mr. Spencer Wells's treatise On Dis- 
eases of the Ovaries. 

The mammary and thyroid glands are also often the seat of similar prolif- 
erous cysts ; and there are proliferous, cysts described by Mr. Paget as recur- 
ring and as cancerous ; while there are others developing skin structures 
(sebaceous), and others developing teeth (dentigerous). 

For more details regarding those, the student must consult Mr. Paget's 
Lectures on Surgical Pathology, a work which has mainly furnished the mate- 
rials for this account of cysts. 



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DEFINITION AND PATHOLOGY OF PARASITIC DISEASES. 143 



PARASITIC DISEASE. 

Latin Eq., Morbus Parasiticus; French Eq., Maln,die Parasiiaire ; German Eq., 
Paradtiche Krankheit ; Italian iiq., Matatiia Parasitica. 

Definition. — Forms of disease in which a great variety of lesions, and of 
symptoms of organic disorder, are brought about by the presence of animal or 
PLANT life, finding a subsistence within or upon some tissue, organ, or surface of 
the human body, or of other animals or plants. 

Pathology. — Parasitic diseases may be considered as due either, — (1.) To 
the existence of parasites from the animal kingdom; or (2.) To parasites from 
the vegetable kingdom ; any one or more of which may live either upon some 
surface, or within a cavity of the body, or within the substance of some of 
its tissues or organs. 

From the animal kingdom we have the entozoa and the epizoa, and from 
the vegetable kingdom the parasitic diseases are due to epiphytes and entophytes. 
It is only recently that we have been able to point with distinctness to a vege- 
table parasite finding its way actually into the substance of animal tissues, 
and there progressing in development. Dr. H. V. Carter, the Professor of 
Anatomy and Physiology in the Grant Medical College of Bombay, has 
described a " 'fungus disease' of the foot, in which numerous minute tubercles, 
resembling fish-roe, lie beneath the muscles," and affect the tissues from the 
Bones to the skin {Trans, of the Med. and Phys. Society of Bombay). 

Plants, as well as man and animals, have their peculiar parasites and para- 
sitic diseases. The mistletoe is a familiar example of a vegetable pjarasite; 
and the oak apple, or gall-nut, is a familiar example of an animal parasite 
affecting a plant. 

It is known, and in many instances it is capable of experimental proof, 
that some of these parasitic diseases (vegetable as well as animal) may be 
transmitted or communicated indifferently from animals to man, and from 
man to animals. The tape-worms, the encysted, vesicular, and round ivorms, 
are examples of parasites intercommunicable among animals ; and Tinea, 
from the "Dartre tonsurante" of the horse, ox, and cat, having been commu- 
nicated from these animals to man, are instances of vegetable parasites inter- 
communicable among animals. It may be that the so-called blights of plants, 
or the causes of them, are also communicable to animals and to man. We 
know that some of the diseases of man and animals are intimately related 
with famines and unwholesome food, and that famines are due more often to 
diseases of vegetable and animal life than to destruction or loss of food. 

The records of history furnish numerous examples of periods of blight in 
the vegetable kingdom, associated with epizootics among the lower animals, 
and with epidemics affecting the human family. (See Sir William Wilde's 
History of Ireland, compiled in connection with the census taken twenty 
years ago [1871].) The relative connection of these events has scarcely yet 
attracted the attention of pathologists, in human or comparative anatomy. 
Here, indeed, is a wide field for investigation — a territory almost yet unex- 
plored. The medical service of Her Majesty's British and Indian armies 
gives golden chances for observation, if the chances are seized at the moment, 
and the observations connected with facts already known. To the more 
salient of these facts the attention of the student is here directed. 

Since the beginning of the present century, when Rudolphi published his 
systematic work on the entozoa (1808), almost every year has contributed 
new and important facts, which render the subject of Parasitic diseases one of 
increasing interest to the pathologist and the physician. The subject abounds 
with most puzzling riddles in natural histoiy and pathology, especially con- 
cerning the reproduction, the development, and the propagation of parasites. 



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144 TOPICS RELATIVE TO PATHOLOGY. 

So long as 180 years ago (1691), the independent nature of such structures 
as the "hydatid cyst" was established by Tyson {Phil. Trans., cxciii, p. 506) ; 
and it was stated by Pallas, iij 1766, that all the cystic worms were forms of 
tape-worms belonging to one species — namely, the cystic or hydatid tape- 
worm ; but it was not then known how their generation and propagation was 
effected. For a very long time the received doctrines regarding the genera- 
tion and development of living beings were tacitly set aside in behalf of such 
"existences." They were believed to arise spontaneously. Inquiry was thus 
set at rest, curiosity seemed satisfied, or investigations followed a fruitless 
direction — as when observations were made on such cysts, in the hope of dis- 
covering in them some evidence of the existence of organs of generation, or 
evidence of some process of generation analogous to what prevails in other 
animals. Ova were looked for, and organs of generation were looked for, 
where neither ova nor organs of generation existed. The calcareous particles 
visible in the tissues of those animals were at one time mistaken for eggs, and 
described as such, in the membrane of the Cysticercus (1841). At last, in 
1842, a great insight was obtained regarding the nature of the generation and 
development of these and other parasites by the publication of facts which 
showed that amongst a certain class of minute Cerearice (worms of a microscopic 
size found in stagnant water), the generation of them was carried on through 
a series of broods produced from one parent, each brood differing from the 
parent and from each other. The discovery of this fact was due to Steeustrup. 
He described the phenomena under the name of " alternation of generation " 
amongst these Cerearice which ultimately live within the body of differen't 
mollusca (Planorbis and Lymnmus). 

These observations gave quite a new direction and impetus to investigation ; 
and Steenstrup himself foretold that the hydatid cysts would be proved to be 
undeveloped tape-worms, each cyst capable of producing a tape-worm after 
its kind. This view was at once taken up, and independently worked out, 
by Eschricht, Nordmann, Von Siebold, Kuchenmeister, Krsemar, Zenker, 
Leuckart, Weinland, in Germany ; Von Benedin, in Belgium ; Dujardin, 
Blanchard, and Robin, in France. 

Many physiologists and physicians of this country have been no less accurate 
observers. Barker, Bristowe, Nelson, Erasmus Wilson, Gulliver, Gull, Jenner, 
Busk, Rainy, Cobbold, and Bastian, may be particularly noticed ; and many 
valuable records have been published in isolated papers by officers of the 
Army Medical Department. The conjoint researches of these extensive 
workers have found most philosophical expositors in this country in Dr. E. A. 
Parkes, the Emeritus Professor of Clinical Medicine in University College, 
and now Professor of Hygiene in the Army Medical School {Brit, and For. 
Med. Review, 1853); in Dr. Allen Thomson, Professor of Anatomy in the 
University of Glasgow {Glasgow Med. Journal, No. x, July, 1855); and 
lastly, in Dr. William Brinton, in the Brit, and For. Med.-Chir. Review for 
1857. From these and many other later sources the following account is 
given relative to parasitic diseases, and their rational treatment. 

Kuchenmeister and Von Siebold were the first to prove by experiment that 
the hydatid or vesicular worms were the young or larval states of tape-worms ; 
and they demonstrated — 

(1.) That each parasite had an independent life of its own. 

(2.) That most animals have each their own peculiar parasites ; that even 
parasitic animals are themselves infested with parasites. 

" So naturalists observe a flea 
Has other fleas on him to prey, 
And these have other fleas to bite 'em, 
And so proceed, adinfinitum." > 

(3.) That some parasites pass or migrate from the body of one animal 
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ELEMENTARY PACTS IN PARASITIC SCIENCE. 145 

into that of another (including man), or from one part of the same animal 
to another cavity or viscus in it. Such migrations are required for the intro- 
duction of the entozoa or their ova into the animals they inhabit, and where 
they undergo those series of changes about to be described, by which they 
reach maturity. 

(4.) That thus, through food or drink, or both, or by bathing in impure 
water, entozoa pass into the human body, finding their way into the most 
delicate tissues, as minute ova or embryos, or as fecundated females like the 
Guinea-worm. 

(5.) That they undergo progressive changes of development towards matu- 
rity in each of the new localities where they find subsistence and protection. 

These are elementary facts in parasitic science ; and the student of Medi- 
cine cannot now rest satisfied with a mere knowledge of the general appear- 
ance of these so-called " worms " as they are found in man and animals. It 
behooves the physician to ascertain their origin, their source, and their mode 
of entrance into the body they inhabit. The easy but unsatisfactory hy- 
pothesis of "spontaneous generation" can no longer be entertained. On the 
contrary, it is now clearly established that all the parasitic entozoa are pro- 
duced more or less directly from fecundated ova. The general and minute 
anatomy of these " worms " must be studied, as well as their modes of gene- 
ration, reproduction, and phases of progressive development ; the various met- 
amorphoses of their individual forms ; and, their transmigrations from one 
animal into another. We must become acquainted with their existence even 
in and upon plants, as well as in other animals besides man, especially in such 
animals or plants as constitute the food of man — fish, flesh, fowl, mollusca, 
and Crustacea, — and especially also all fresh-water plants, or plants which 
grow on moist ground. 

But domestic animals which are not generally eaten, but which, being the 
companions of man, come, like him, to be infected with parasites, and so tend 
to promote their propagation alike in man and other animals, require atten- 
tion, as to their feeding and habits. 

A knowledge of details relative to the generation and reproduction of para- 
sites is also absolutely necessary .in order to appreciate the nature of parasitic 
diseases. Indeed,' without such knowledge no advance is likely to be made 
in the prevention of these diseases. It is this kind of knowledge which has 
recently led to most important practical results in the history of animal para- 
sites ; and which most of all seems capable of extending our knowledge of 
parasitic diseases, especially in relation to human pathology, to the rational 
treatment of parasitic diseases, and especially their prevention. 

Parasites of animal organization exist in man and animals in every grade of 
development ; and the first lesson for the student to learn is, — how to distin- 
guish entozoa which are sexually complete from those parasitical productimis 
which are destitute op sexual organs, which are immature larvae, or 
NON-SEXUAL PARASITES, b\d u'hich have long been regarded as distinct animals. 

The following is a classified list of Human Parasites, as given by the Royal 
College of Physicians of London, in the Appendix to their Nomenclature, 
p. 232. 



10 



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146 TOPICS RELATIVE TO PATHOLOST. 



HUMAN PARASITES. 



The Parasites are to be returned as registered under Local Diseases. 



SUBDIVISIONS. 
1. Entozoa. 

2 ECTOZOA. 

3. Entophyta and Epiphyta. 

ENTOZOA. 



A. CcBLBLMiNTHA. English synoni/m,Jl-ol\ow 'Worms. Definition: Worms with 

an abdominal cavity. 

B. Stebelmintha. English synonym. Solid worms. 

c. Accidental Parasites. Definition : Internal parasites, having the habits, 
but not referable to the class, of entozoa. 

Class A. Ccelblmintha. 

1. Ascaris lurnbrieoides. (Linnseus.) Habitat: Intestines. 

2. Ascaris my stax. (Rudolph!) Habitat: Intestin-es. 

3. Trichocephalus dispair. (Rudolphi.) Habitat: Intestines. 

4. Trichina spiralis. (Owen) Habitat: Muscles. ^ 

5. Eilaria medinensis. (Gmelin.) Synonym, Dracunculus medinensis. English 

synonym, Guinea- worm. Habitat: Skin and subcutaneous tissues. 

6. Pilaria oculi. (Nordmann.) Si/noni/m, Filaria lentis. (Diesing.) Habitat: Eye. 

7. Strongylus bronchialis. (Cobbold ) Habitat: Bronchial tubes. 

8. Eustrongylus gigas. (Diesing.) Habitat: Kidney and intestines. 

9. Sclerostoma duodenale. (Cobbold.) S't/momym, Anchylostomum duodenale. Habi- 

tat: Duodenum. 

10. Oxyuris vermicularis. (Bremser.) English synonym. Thread-worm. Habitat: 

Bectum. 

Class B. Sterblmintha. 

11. Bothriocephalus latus. (Bremser.) T. lata. (Linnaeus.) Habitat: Intestines. 

The broad tape-worm endemic to man in some localities only. Its embryo is 
ciliated and developed in water (Knoch). 

12. Bothriocephalus cordatus. (Leuckart ) Habitat: Intestines. Recently found in 

North Greenland. 

13. Taenia solium. (Linnaeus.) Habitat: Intestines. 

14. Cysticercus of the Taenia solium. Synonym, Cysticercus telse cellulosae. (Rudol- 

phi.) The larva or scolex of the T. solium 

15. Taenia mediocanellata. (Kiichenmei.ster.) Habitat: Intestines. 

16. Taenia acanthotrias (Weinland.) Habitat: Intestines. 

17. Taenia flavopuneta. (Weinland.) Habitat: Intestines. 

18. Taenia nana. (Siebold.) Habitat; Intestines. 

19. Taenia lophosoma. (Cobbold.) Habitat: Intestines. 

20. Tasnia eliiptica. (Batsch.) ifaftite^.' Intestines. 

21. Cysticercus of the Taenia marginata. Synonym, Cysticercus tenuicollis. 

22. Echinococcus hominis, or Hydatid of the Taenia echinococcus. (Siebold.) 

23. Pasciola hepatica. (Linnaeus.) Habitat: Liver. 

24. Distoma crassum. (Busk) Habitat: Duodenum. 

25. Distoma lanceolatum. (Mehtis.) Habitat: Hepatic duct ; intestines 

26. Distoma ophthalmobium. (Diesing.) Habitat: Eye. 

27. Distoma heterophyes. (Siebold.) Habitat: Small intestines. 

28. Bilharzia haematobia. (Cobbold.) i/uAiiai.- Portal and venous blood. 

29. Tetrastoma renale. (Delia Chiaje.) Habitat: Tubes of the kidney. 

30. Hexathyridium venarum. (Treutler.) Habitat: Venous blood. 

31. Hexathyridium pinguicola. (Treutler.) Habitat : Ovary. 

Class C. Accidental Parasites. 

32. Pentastoma denticulatum. (Siebold.) Habitat: Liver; small intestines. 



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MIGRATIONS OF PARASITES. 147 

33. Pentnstoma constrictura. Habitat: Liver and lung; Negroes on West Coast of 

Africa. 

34. Oestrus hominis. (Say.) English synonym, Larva of the gad-fly. Habitat: In- 

testines. 

35. Anthomyia canicularis. (A. Parre.) Habitat: Intestines; and exciting causes 

of boils by their larva. 

ECTOZOA. 

36 Phthirius inguinalis. (Leach.) English synonym, CTahAoase. 

37. Pediculus capitis. (Nitzsch.) 

38. Pediculus palpebrarum. (Le Jeune in Guillemeau.) 

39. Pediculus vestimenti (Nitzsch.) English synonym. Body-louse. 

40. Pediculus tabescentium. (Burmeister.) 

41. Sarcoptes scabiei. (Latreille.) Synonym, Acarus. English synonym. Itch-insect.* 

42. Demodex folliculoriim. (Owen.) 

43. Pulex penetrans. (Gmelin.) English synonym. Chigoe. Habitat: Skin and cel- 

lular tissue. 

Entophyta and Epiphyta. 

44. Leptothrix buccalis. (Wedl. Robin.) English synonym, A\gSi o{ the moath. 

45. Oidium albicans. (Link.) English synonym, Thrush fungus. Habitat: Mouth 

in cases of thrush, and certain mucous and cutaneous surfaces. 

46. Sarcina ventriculi. (Goodsir.) Habitat: Stomach. 

47. Torula oerevisise. (Turpin.) Synonym, Cryptococcus cerevisiffi. (Kiitzing.) 

English synonym. Yeast-plant. Habitat: Stomach, bladder, &c. 

48. Chionyphe Carteri. Definition: A cotton fungus occurring in the disease called 

Mycetoma. Habitat: Deep tissues, and bones of the hands and feet. 

49. Achovion Schonleini. (Remak.) Habitat: Tinea favosa. f 

50. Puccinia favi. (Ardsten.) Habitat: Tinea favosa.f 

51. Achorion Lebertii. (Robin ) Synonym, Trichophyton tonsurans. (Malmsten.) 

Habitat: Tinea tonsurans. f 

52. Microsporon Audouini. (Gruby.) Habitat: Tinea decalvans.f 

53. Trichophyton sporuloides. (Von Walther.) Habitat: Tinea Polonica.-j- 

54. Microsporon furfur. (Eichsladt. ) Habitat: Tinea versicolor. f 

55. Microsporon mentagrophytes. (Gruby.) Habitat: Follicles of hair in Sycosis or 

Mentagra.f 

The foregoing list might be extended by the addition of various parasitic vegeta- 
tions, which have been reported under the names of Algse, Eungi, Mycoderms, 
Leptomiti, &c., but the characters or the existence of which are still the subject 
of inquiry. 

The distinction between mature and immature parasites has not been main- 
tained in the classification ; but in the description about to be given, it is . 
necessary that this distinction shall be maintained. 

The sexually mature entozoa inhabit either the alimentary canal of animals 
or the cavities of the lungs ; or, to express it generally, they inhabit such 
parts of the body as are in immediate or free communication with the exter- 
nal air. On the other hand, the non-sexual or immature entozoa, while para- 
sitic, all live inclosed in cysts ; such cysts being situated either in the 
parenchyma of organs, like the liver or lung, or in close internal cavities — 
e. g., the peritoneum, pleura, pericardium, or eye, within secreting tubes, blood- 
vessels, and the like. In such places these non-sexual parasites are all 
proved to be incomplete animals. They are the embryos, larvse, or early 
forms of entozoa, which only attain to sexual maturity by migration from the 
place of their earlier abode into the alimentary canal, or pulmonary, or other 
open cavity of different animals. Or, leaving their encysted parasitic state 
in the condition of larvse, they reach maturity in a free state (i. e., liberated 
from their encysted condition), when they are developed in water, in earth, 
mud, or upon moist plants, or in other conditions favorable for them. 

* The disease Scabies to' be returned amongst the parasitic diseases of the skin, 
f To be returned amongst the parasitic diseases of the skin. 

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148 TOPICS RELATIVE TO PATHOLOGY. 

The cystic or vesicular entozoa (established by Rudolphi as a separate 
order of parasites) are to be distinguished from those which are not vesicular, 
but which are also inclosed in cysts. Some of the early parasitic forms of 
round -worms, as well as others, are thus inclosed in cysts ( Trichina spiralis) ; 
but they are not cystic or vesicular. Fig. 33, is an example of a cystic 
parasite — e. g., Cysticercus twnia mediocanellata ; Fig. 13, p. 154, of an en- 
cysted round worm — Trichina spiralis. All entozoa so encysted, whether they 
be cystic or round worms, are found to be immature ; and in no instance has 
the encysted entozoon been known to attain sexual completeness, however 
well grown it may appear to be, so long as it remains inclosed in a cyst. 
Sometimes cysts only are found, which may be identified as pathologically 
altered conditions of cystic or encysted entozoa. When free, all these entozoa 
come at last to acquire sexual organs, and, when they have arrived at matu- 
rity, they exercise the function of sexual reproduction. The number of fecun- 
dated ova which most of them produce is enormous. In a tape-worm or ascaris, 
there are many millions ; but " the struggle for existence " consigns the greater 
part of them to death as the food of others, such as birds, or fish, or animals 
unfavorable to their growth as parasites. 

The process of fecundation and the development of the embryo from the 
ovum have now been actually observed in a considerable number of the para- 
sitic entozoa ; and it is to be remembered, as a general fact, that the develop- 
ment of the ova rarely takes place in the same animal, or in the same part 
of an animal, where the parent parasitic entozoon has passed its life and has 
exercised the generative iunction. There is either a migration from a para- 
sitic to a free condition for a time (e. g., Chdnea-worm, Ascarides, Cercarice) ; 
or from one animal into another animal, the free condition intervening (e. g., 
Bothriocephalus) ; or, lastly, the migration may take place from one part to 
another of the same animal who is the unfortunate host (e. g., Trichina spi- 
ralis; and cases of tape-worm giving rise to Oysticercus). Some entozoa, known 
only as incomplete or immature animals in the parasitic mode of life, attain 
to sexual maturity in the free state ; others again, and perhaps the greater 
number, after living free for a time, become sexually complete in the parasitic 
condition (e. g., the Ascarides and the JBothriocephalus). 

" The migrations or changes of habitation of the entozoa, or their ova or 
embryos, appear to take place in a variety of ways : first, by their being 
passed out of the body of the inhabited animal with the faeces or other excre- 
tions ; second, by their being introduced into the bodies of inhabited animals 
with their food or drink ; third, by their directly piercing the integument or 
other tissues ; fourth, by their piercing the membranes and parenchyma, en- 
tering the bloodvessels, being distributed through them, and subsequently 
piercing their coats to attain other situations. 

"Some of these entozoa are directly developed from their ova, without 
undergoing more remarkable changes than those which are known usually 
to accompany the process of embryonic evolution in many other animals. 
Other entozoa are subject to individual metamorphoses, or the embryo passes 
through successive stages of development of so remarkable a character as to 
mark the regular sequence of the phenomena of progressive formation. There 
are others of the entozoa which are subject to still greater changes in the 
progress of their existence, — changes upon which great light has recently 
been thrown by the remarkable researches of Steenstrup and others, in regard 
to what has been called alternate generation or metagenesis. Thus some of 
the_ entozoa, by a non-sexual process, undergo that peculiar form of multipli- 
cation in which the immediate progeny of development from the ovum is dis- 
similar from the parent, but produces, without the aid of sexual organs, 
another progeny, which either itself, or by repetition of an analogous process, 
returns to the parental form. This is a process of the nature of an internal or 



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MIGRATIONS OF PARASITES. 1"49 

external gemmation, which is often attended with a prodigious multiplication 
of the number of individuals. In some entozoa, again, metamorphosis and 
metagenesis are combined. It is obvious that the external conditions neces- 
sary to maintain these varieties of the vital states must be diiferent" (Allen 
Thomson, Glasgow Med. Journal, 1. c). 

The lesions and diseases caused by the existence of parasites rather tend to 
embitter existence than to cause death ; and they are especially frequent 
amongst soldiers. With one exception — namely, in the case of the immature 
cystic parasites — the disorders induced are, as a rule, not severe ; indeed, it 
is a condition of parasitism that it should not actually destroy the life of the 
animal from which it derives its own subsistence. 

It is the immature parasites which tend to destroy the life of their host, by 
the severe lesions they induce, and the destruction of the parts which they 
cause, when they pass from one place to another, or from one state to another 
onwards to maturity. Thousands of mature worms infest children, yet they 
do not appear ill. But such is not always the innocent history even of the 
mature worms, — undefined illnesses, violent and sudden pains, febrile phe- 
nomena like typhoid or rheumatic fever, chronic inflammations, wastings, 
convulsions, chorea, epilepsy, amaurosis, apoplexy, giddiness (staggers in 
sheep and horses), are the grave results which sometimes befall human or 
other animals who may become the unfortunate hosts of such undesirable 
guests as mature or immature parasites. Dr. Heslop, of Birmingham, has 
especially called my attention to the fact, that the accounts given of the cere- 
brospinal symptoms of worms are remarkably defective ; and he kindly sen{ 
me part of an essay of his on the subject, originally printed in the Dublin 
Quarterly Journal, No. 55. The following are his conclusions : 

"1. That in the great majority of cases of tape-worm, and, though with 
lesser frequency, in cases of other intestinal worms, more or less serious and 
peculiar nervous disturbances are apt to arise. 

"2. That the most frequent of these are headache, giddiness, various 
troubles of the special senses, especially singing in the ears, flashes and dark 
spots before the eyes, imperfect amaurosis, and trembling of the limbs. 

" 3. That various ansssthetic, and, on the contrary, neuralgic phenomena, 
are very frequent, usually connected with general lassitude and sense of mus- 
cular feebleness. 

"4. That, though less frequent than those previously cited, convulsive 
seizures, partaking of the nature of epilepsy or acute eclampsia, or sudden 
attacks of insensibility, mixed with syncope, and, in the female sex, severe 
forms of hysteria, are also often directly traceable to worms. 

" 5. That the last symptoms (No. 4) are more common in childhood and 
the earlier periods of life than afterwards, and are more frequently caused by 
the round and thread-worms than by tape-worm. 

" 6. That chorea does not appear to be often excited by the irritation of 
worms. 

" 7. That a feeble state of the general health generally accompanies the 
presence of worms ; often, in cases of taenia, proceeding to marked ansemia, 
so as even to lead to the suspicion of the possible existence of Bright's disease. 

" 8. That the irritative phenomena of the digestive tube, even when asso- 
ciated with various symptoms referred to the fiinctions of that tract, do not 
warrant the diagnosis of the presence of taenia ; and that their absence does 
not absolutely indicate the absence of -the parasite. 

" 9. That the frequent appearance of the nervous symptoms above related, 
without a well-marked relation to any special lesion of the nervous system, 
especially if alternating, with periods of perfect or nearly perfect freedom, 
should engender the suspicion that worms are present. If to these symptoms 
are added various ill-defined disturbances of the functions of assimilation. 

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150 TOPICS RELATIVE TO PATHOLOGY. 

including occasionally colicky pains, without marked vomiting, pain after 
food, or decided emaciation, it is in the highest degree probable that -worms 
are the source of the symptoms. 

" 10. That it is probable that many of the symptomatic phenomena of ver- 
mination are connected not with their direct irritation of the mucous mem- 
brane with which they are in relation, but with a general disorder of the sys- 
tem, partly resulting from the parasites, and partly the cause of their main- 
tenance and development in the intestinal tract." 

Sometimes even death is the result. But in any case the prevalence of 
parasitic disease in animals comes in the end to be a national loss, affecting 
the health and wealth of nations, by rendering the flesh of many animals used 
as food innutritions, or altogether unfit for use. 

Following out the arrangement in the Table at pp. 146-147, a detailed de- 
scription of those parasites will now be given, and of the lesions associated 
with them, commencing with — 



I. — Entozoa. 

CLASS A. — CCELELMINTHA, OE HOLLOW WORMS. 

Definition. — Worms of an attenuated cylindrical form, with an abdominal 
cavity, in which an intestinal canal is suspended free. They are possessed of a 
mouth and anus, and have the sexes distinct. 

Patholog'y. — In their mature state these worms inhabit the alimentary 
canal, the pulmonary tubes or areolar tissue of man and animals. In their 
immature state some are encysted in the human body, and others come to 
maturity in the open waters. In the human subject they are represented by 
the Asearides, the Oxyurides, the Triehinm, the Sclerostoma, the Strongylus, 
the Speroptera, and the Filarice. 

A knowledge of the generation of these round worms is of the utmost impor- 
tance for preventing their occurrence in man. The generative organs of these 
nematoid worms are adapted for the reproduction of an enormous number of 
fertile ova. They are male and female; but the males, as a rule, are scarcer 
and smaller than the females. 

The fertility of these animals is enormous. Dr. Eschricht has made an 
elaborate calculation regarding the A. lumbricoides, the commonest parasite 
of man. The ova being arranged like flowers upon a stem in the ovary tubes, 
he has counted fifty in a circle, or in every transverse section. The thickness 
of each ovum he estimates -j-J^th of a line (= -j^-^th of Jjth = g^ijtli of an 
inch) ; so that in every line of length of the worm there would be 500 wreaths 
of 50 eggs each, == 25,000 eggs. 

The length of each horn of the uterus is taken at sixteen feet, which gives 
2304 lines ; and for the two horns it will give 4608 lines. The eggs, how- 
ever, gradually get as large as -jJoth of a line, so that only sixty wreaths of 
eggs come to be on one line, or about 3000 ova ; and an average gives 14,000 
ova in a line — i. e., sixty four millions of ova in every mature female Ascaris. 

What becomes of all these ova? The embryo is not developed within the 
body of all of these parasites ; and the source of the various Asearides which 
inhabit man is not yet fully known. 

The ova being discharged by millions, many of them in large cities are 
carried into streams of water. An extremely small proportion is ever likely 
again to find their way into the alimentary canal of the animal which was 
the dwelling-place of the parents of these ova. Thus they become food for 
numerous inhabitants of the water, and therefore stand in the same relation 
to many of these animals as the cerealia in the vegetable kingdom to the 

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INCUBATION OF OVA OP ROUND WORMS. 151 

higher animals on land. Indirectly they thus contribute to the sustenance of 
man and animals. 

But on the other hand, there are many circumstances which tend to show 
that the A. lumhricoides is most frequently introduced as a minute embryo 
with water, or with fresh uncooked vegetable food. 

Dr. Paterson, an eminent physician in Leith, observed that certain families 
who drew water from a public well in a particular street there, were very 
subject to the A. lumhricoides; while towards the other end of the same street 
. the families were supplied by the pure water which supplies Edinburgh and 
its vicinity ; and these families were free from the parasite. The water of the 
well came from a dirty pond or lake in the vicinity (called Lochend), and in 
its water numerous vermiform animalcules existed, such as the Anguillula 
fluviatilis, perhaps the embryonic form of an Agearis. 

Another point to be remembered in all inquiries of this kind is the intense 
tenacity of life, and revival from a state of apparent death, exhibited by these 
parasites ; and in no class of animals has the origin by spontaneous genera- 
tion been more strenuously contended for than in regard to these entozoa. For 
example, there is a minute worm of a nematoid kind which is a parasite upon 
wheat grains (the Vibrio tritiei) ; some of these being dried, and then remoist- 
ened after a lapse of four to seven days, they resumed their living active state 
(Bauee, in Phil. Trans., 1823, p. 1, quoted by Owen). Dr. Blainville has 
given other similar instances of revival after desiccation ; and mature entozoa 
will even resist the effects of such destructive agents as extremes of heat and 
cold, to a degree beyond the endurance of any other minute animals. Owen 
relates that a nematoid worm has been seen to exhibit strong contortions — 
evident vital movements — after having been subjected above an hour to the 
temperature of boiling water with a codfish which it infested. Eudolphi 
mentions of some entozoa which infest herrings annually sent to Berlin hard 
frozen and packed in ice, that .they do, when thawed, exhibit unequivocal 
signs of restored vitality (Owen, Lectures on the Invertebrata, p. 80). lAgulm 
are often found alive in undercooked codfish. Eudolphi found individuals of 
Ascarides (spiculigerd) -stiff and hard in the gullet and stomach of a bird 
(eormoranf) kept in spirits of wine for eleven days, and which returned to life 
in warm water. Miram has seen individuals of the Ascarides (acus) from the 
pike become dry, and remain sticking to a board, where they would revive 
again by being placed in water, and in some instances they would move a 
part of the body which had imbibed the fluid, while the remaining part con- 
tinued shrivelled up, and adherent immovably to the board. I have seen the 
same results in the Ascaris which infests the peritoneal covering of the mack- 
erel. Such being the tenacity of life on the part of the mature animal, how 
•much more do the ova possess the powers of endurance? Without losing 
latent life, they even develop themselves under circumstances of the most im- 
probable kind. Dr. Henry Nelson and Dr. Allen Thomson have observed 
the development of the ova of the A. mystax to proceed for several days, while 
the parent bodies containing them were immersed in oil of turpentine. I 
have once seen the same occurrence ; and also I have seen the development of 
the embryo proceed in spirits of wine for about three weeks before signs of 
vitality had ceased. 

Periods of Incubation of the Ova. — The eggs are ovoid, and covered by a trans- 
parent envelope or chorion, which, after fecundation and segmentation, becomes . 
tuberculated. Hence the various accounts given as to their surface appear- 
ance. They are expelled with the fseces in the case of the A. lumhricoides. 
They have been placed in water and taken care of for various lengths of time, 
and Richter records, that at the end of eleven months each ovum contained a 
living embryo. In August, 1853, Verloren and Richter put a fragmennt of 
a mature female Ascaris (marginata of the dog) into water, so as to keep the 
ova moist merely ; and he examined them from time to time with the micro- 

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152 TOPICS RELATIVE TO PATHOLOGY. 

scope. Segmentation having commenced, the development of the young was 
completed in fourteen days. They moved with great briskness within the 
egg-shells, hut did not break through them. In this imprisoned or encysted 
state they continued throughout autumn a-itdujinter; the movements of the 
embryos gradually diminishing, and at last entirely ceasing during the winter 
months, to recommence in the following spring, and become again distinct in 
summer. But, they never broke through the shell. 

The condition of these Ascarides from the encysted state of inclosure within 
the egg is only changed under favorable circumstances — ^namely, when the 
animals are liberated and carried on to further development ; and now it is 
known that the embryo of nematoid worms may pass the winter in a torpid 
state, floating about in the open waters, or lying in moist places. , The fully- 
formed embryo is cylindrical, its length y^th of an inch ; the mouth is not 
furnished with the three characteristic papillae of the genus, and the tail ter- 
minates suddenly in a point. It is highly probable, from the evidence, that 
the embryos are directly transferred to the alimentary canal of man from 
river and pond-water. 

1. The Ascaris lumbricoides, or round worm, is perhaps the most anciently 
known, and is the most common of human entozoa. It is now regarded as 
specifically distinct from the A. megaloc&phala of the horse and the A. suilla of 
the hog (DujAEDiN, Moquin-Tandon, Cobbold). It is much more common 
in children and adults than in old people. The body is long (six to sixteen 
inches), round, elastic, and attenuated towards both extremities, but more 
attenuated towards the anterior end. It is of a grayish-red color, and suf- 
ficiently translucent to permit its viscera to be seen through its coverings. 
The Ascarides inhabit chiefly the small intestines, but may pass up into the 
gall-ducts, the stomach, the oesophagus, the nostrils, the mouth, or frontal 
sinuses ; and there are cases on record and specimens in museums where the 
worm has evidently penetrated the coats of the intestine, and got into the peri- 
toneum or into the pleura. It sometimes makes its way by the bile-ducts into 
the liver, and leads to hepatic abscesses. An interesting example of this may 
be seen in a preparation in the museum of the Army Medical Department at 
Netley. In some cases they are so numerous as absolutely to obstruct the 
intestines ; in others only a solitary worm, or a pair, may be found. Three 
distinct tubercles surrounding the mouth characterize the genus. The pos- 
terior end is obtuse ; but is straighter and thicker in the female than in the 
male. It is abruptly acute and curved in the male. An anus is situated in 
both sexes close to the tail, and in form is like a transverse fissure. In the 
female the body presents a constriction at thejunctionof the anterior Avith the 
middle third ; and here the vulva is situated. The parasite throughout is 
marked with transverse furrows and with fine striae. Longitudinal equidis- 
tant lines run from the head to the tail, and are independent of the exterior 

■ envelope. 

2. The A«earis mystax, which infests every domestic cat, must now be 
regarded as a human parasite (Pickells, Bellingham, Cobbold). It varies 
from an inch and a half to two or three inches long, its head end being spear- 
shaped, in consequence of two lateral processes, from which it has been named 
A. alata. The ova have the embryo developed within them before they escape 
from the parent, and in this respect they resemble the Oxyuris vermicularis. 
(See description of the Oxyuris vermicularis.) 

3. The Trichocephalus dispar occurs in the caecum and colon, and was first 
noticed by Morgagni. A little more than a hundred years ago (1760-61) a 
student of Gottingen was dissecting the valve of the colon of a girl five years 
of age. He accidentally opened the gut, and several of these entozoa came out. 
Wrisberg and other students considered the worm a new one ; but the demon- 
strator of anatomy maintained that it was an Ascaris or an Oxyuris, and a dis- 
pute arose. At last the new parasite got a name as a new worm, and was 



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DESCRIPTION OF THE TRICHINA SPIRALIS. 153 

called a Triohinalis or hairtail. But it afterwards turned out that its^eacZwas 
hair-like, and not its tail, so it has been since called Trlahocephalus. About 
this same time an epidemic raged in the French army stationed at Gottingen, 
and the disease was described under the name of the Morbus mucosits. This 
entozoon was frequently found in the bodies of the soldiers who died during 
the epidemic of this mucous flux. 

It is said to be very common in persons attacked with typhus fever; 
and is found in those dying with excessive discharges from the bowels, as in 
cholera and diarrhoea. 

It is found in France, England, Egypt, Ethiopia, and rarely in Italy ; 
abounding particularly in the caput ccecum. It is generally thought to be 
scarce in England — a persuasion which Dr. Cobbold thinks has probably 
arisen from " the negligence of pathologists, whose arduous duties connected 
with the superintendence of post-mortem examinations have, perhaps, left 
them little time for these inquiries." On the other side of the Channel this 
parasite is so abundant in some localities, that not less than one-half the 
inhabitants of Paris are affected by it (Duvaine). 

These parasites are males and females, in separate sexes, varying from one 
and a half to two inches. 

The anterior extremity, carrying the head, is the narrow hair end, and it is 
usually buried in the mucous membrane of the intestines, while the remainder 
of the body moves freely in the midst of the mucous secretion, generally coiled 
upon itgelf.' 

The males are shorter than the females, and less thick posteriorly, with a 
long spiculum. The eggs are oval, with resisting shells jTijth of an inch in 
length. 

4. The Trichina spiralis was first seen by Tiedemann in 1822, and de- 
scribed by Mr. Owen in 1835 from a specimen taken to him by Mr. Paget. It 
has since been often recognized chiefly as a dissecting-room curiosity. The 
student tries in vain to clean the fibres of the muscle he is dissecting, which, 
however clearly displayed, still looks as if it were " sprinkled over with the 
eggs of some insect." 

Instances of the T. spiralis in the muscles of the human body are of much 
more frequent occurrence than has generally been supposed. Most probably, 
from their very minute size, they have hitherto been overlooked, and the 
symptoms of illness produced by their presence been mistaken for enteric fever 
and rheumatism,. Virchow had not seen a" case before 1859, after which he 
met with no less than six in one year. It is perhaps more common in man 
than even the Cysticercus. Zenker, of Dresden, found Trichince in four out of 
136 dissections — i. e., one in thirty-four. 

Of late, however, much interest has been excited in this subject ; for, in 
place of the T. spiralis being quite a harmless parasite, as has been hitherto 
the belief, Zenker has lately shown that it is the source of a new and most 
alarming form of disease ; that, in place of remaining harmless and encysted 
in its capsule, only to cretify or degenerate, it may free itself from this cyst, 
and, migrating amongst the muscles, may give rise to symptoms of the most 
serious kind, causing death in a strong and healthy person after a few weeks 
of painful suffering. 

It seems, indeed, to be the most dangerous of all parasites — not even ex- 
cepting the Ecliinoeoocus ; and it behooves the physician to know something 
about the nature, origin, and development of this entozoon, seeing that its 
pathological relations are now known to be of extreme importance and interest. 

Hitherto the T. spiralis has been known as a minute round worm, inclosed 
in a more or less transparent capsule, lying between the sarcolemma_ of the 
primitive muscular fibres (Figs. 13, 14) ; but when the parasite is free, it finds 
its way within that sheath. It forms the type of a distinct genus of nematodes, 
having no genetic relations with the Trichocephalus dispar, as was supposed ; 

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154 



TOPICS RELATIVE TO PATHOLOGY. 



but is reproduced viviparously. The non-encysted Trichiim may exist in the 
flesh of animals without being visible to the naked eye. In the encysted state 
they are difficult of detection without the aid of a lens, if cretification has not 
commenced in the cyst. The cysts are round or elongated, and appear, 
according to their shape, like small round dots, granules, vesicular, or streaks, 



FlQ. 13. 





Slightly magnified cyst of TrUMna 
spiralis i,after Virchow). 



100th of an inch X -MO. 

The Trichina spiralis removed from its 
cyst (after Virchow). 



grayish-white or opaque, and quite distinct from the red transparent muscle. 
When the cyst has loecome calcareous, its limey material may be dissolved 
away by acetic or hydrochloric acid with the evolution of gas, and the para- 
site is then seen coiled up within (Fig. 13). 

The following account of this parasite is given by Dr. Cobbold, from his 
own observations and those of Leuckart : 



"(DThe Trichina qnralis, in its mature state, is an extremely minute 
nematode helminthe ; the male, in its fully developed and sexually mature 
condition, measuring only y'gth of an inch, whilst the perfectly developed 
female reaches a length of about y ; body rounded and filiform ; usually 
slightly bent upon itself, rather thicker behind than in front, especially in 
the males ; head narrow, finely pointed, unarmed, with a simple central minute 
oral aperture ; posterior extremity of the male furnished witli a bilobed caudal 
appendage, the cloacal or anal aperture being situated between these diver- 
gent appendages ; penis consisting of a single spicula, cleft above, so as to 
assume a V-shaped outline ; female shorter than the male, bluntly rounded 
posteriorly, with the genital outlet placed far forward, at about the end of the 
first fifth of the long diameter of the body ; eggs measuring ^t}^-^" from pole 
to pole ; mode of reproduction viviparous. (2. ) The sexually mature trichina 
inhabits the intestinal canal of numerous warm-blooded animals, especially 
mammalia (also of man), and constantly in great numbers. ( 3.) At the second 
day after their introduction, the intestinal trichiuaj attain their full sexual 
maturity, lose their spiral figure and become stretched, whilst they grow rap- 
idly, and their generative organs are developed. (4.) Most females contain 
from three to five hundred ova. In six days the female parasites will contain 
perfectly developed and free embryos in the interior, and these, on attaining 
full size, pass out at the vaginal opening. The eggs of the female trichina 
are developed, within the uterus of the mother, into minute filaria-like em- 
bryos, which from their sixth day are born without their egg-shells. ( 5.) The 



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DESCRIPTION OP TRICHINA SPIRALIS. 155 

new-born young soon afterwards commence their wandering. They pene- 
trate the walls of the intestines, and pass directly through the abdominal 
cavity into the muscles of their bearers, where, if the conditions are otherwise 
favorable, they are developed into the form hitherto known. (6.) The direc- 
tion in which they proceed is in the course of the intermuscular connective 
tissue. (7.) The majority of the wandering embryos remain in those sheathed 
muscular groups which are nearest to the cavity of the body (abdomen and 
thorax), especially in those which are smaller, and most supplied with con- 
nective tissue. (8.) The embryos penetrate into the interior of the separate 
muscular bundles, and here already, after fourteen days, acquire the size and 
organization of the well-known Trichina spiralis. (9.) Soon after the intru- 
sion of the parasite, the infested muscular fibre loses its original structure. 
The fibrillse collapse into a finely granular substance, whilst the muscular 
corpuscles change into oval nucleated cells. (10.) The infested muscular 
bundle retains its original sheathing up to the time of the complete develop- 
ment of the young trichinae, but afterwards its sarcolemma thickens and be- 
gins to shrivel at the extremities. (11.) The spot inhabited by the roUed-up 
parasites is converted into a spindle-shaped widening, and within this space, 
under the thickened sarcolemma, the formation of the well-known lemon- 
shaped or globular cysts commences by a peripheric hardening aud calcifica- 
tion. One cyst may have from one to three trichinae. (12.) The migration 
and development of the embryos also take place after the transportation of 
impregnated trichinse into the intestines of a new host. (13.) The further 
development of the muscle trichinse into sexually mature animals is altogether 
independent of the formation of the calcareous shell, and occurs as soon as 
the former have reached their completion. The male and female individuals 
are already recognizable as sexually distinct in their larval state." (Entozoa : 
an Introduction to the Study of Hdminthology, with reference more particularly 
to the Interrml Parasites of Man, by T. Spencer Cobbold, M.D., F.R.S. Lon- 
don, 1864.) 

The symptoms of the disease induced by this parasite are at first of a febrile 
nature, having a close resemblance to some forms of specific fevers. Dr. Philip 
Frank, lately Assistant Surgeon on the Staff of Her Majesty's Army Medical 
Department, was the first to send an account of this remarkable disease from 
Germany to this country. He described a case of its occurrence in the Medical 
Times and Gazette of May 26, 1860 ; and recently Dr. Parkes has given a short 
notice of trichina disease in the Sanitary Report of the Army Medical Depart- 
ment for 1860, p. 351. The history of the case referred to by Dr. Frank is as 
follows : 

In January, 1860, a servant girl about twenty years of age died in the 
Dresden Hospital from the effects of the T. spiralis; and the muscles of her 
body furnished materials for numerous observations and experiments, which 
have thrown much light on the origin and development of this parasite. The 
illness of the patient commenced about Christmas, 1859 ; and the symptoms 
may be arranged into two sets: (1.) Extreme lassitude, depression, sleepless- 
ness, loss of appetite, and eventually febrile phenomena which were well ex- 
pressed, so much so, that the case was set down as one of typhoid fever ; but 
grave doubts prevailed, for (2.) A new train of symptoms developed them- 
selves — namely, the whole muscular system became the seat of excruciating 
pain, especially in the extremities. Contractions of the knee and elbow joints 
supervened, and associated with such extreme pain as to render extension of 
the limbs impossible. Oedema of the legs followed; and the case terminated 
fatally by pneumonia, about the twenty-eighth or thirtieth day after the first 
symptoms of illness. 

A post-mortem examination of the body showed the muscles moderately 
developed, of a pale reddish-gray color, and dotted over with specks, which 
turned out to be groups of non-encapsuled Trichinm, lying free upon and within 

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156 TOPICS RELATIVE TO PATHOLOGY. 

the sheaths of the muscular fibres. They were alive — some coiled up and 
others lying straight ; and they appeared to be in all stages of development, 
diffused throughout all the striated muscles of the body, not even excepting 
the heart itself. They abounded in such vast numbers that as many as 
twenty Trichince -were seen in the field of view through a low magnifying 
power, the muscular tissue being everywhere in a degree of very marked de- 
generation. In the jejunum were found sexually mature Trichince. Death 
was due to the development of the T. spiralis, whose existence fully explained 
the anomalous symptoms which attended the ease. 

On looking into the history of the girl, it was found out that she had been 
a servant in a farm-house, and had been taken ill very soon after the killing 
of two pigs and an ox — animals which it is customary to kill about Christmas. 
Pigs are known to be infested with the T. spiralis — so are oxen ; and Professor 
Zenker went to the master's house, and found some ham left of the identical 
pig that had been there killed, and also some sausages. The flesh of the pig 
was examined microscopically, and every specimen examined showed that the 
pig's flesh was infested with Trichince in the encysted state. At same time 
Professor Zenker learned that, soon after the girl had been taken ill, the 
housekeeper also became unwell, with similar symptoms, but in a less severe 
degree ; and all the servants about the farm became more or less ill about the 
same time. The house of the butcher who had killed the pig was then visited 
by Professor Zenker, who was informed by the wife of the butcher that he had 
been very ill since that event. He had been three weeks in bed, suffering 
from rheumatic pains in the limbs, and had been as if paralyzed over his body 
— unable to move his arms, legs, or neck. He had never suffered anything 
of the kind before, but had always been a he'althy and strong man. He 
thought he had caught cold the day he killed the pig; but when it is 
known to be a habit of German butchers to taste the meat they kill, in the 
raw condition, the history of these cases, to Professor Zenker, became a history 
of trichinatous disease — the development and growth to maturity of the T. 
spiralis in the muscles of those who lived at the farm-house, as well as of the 
butcher who had killed the pig, and who no doubt had eaten some of its 
flesh. 

Numerous experiments were made with the flesh of the girl who died in 
this remarkably morbid state. Portions of the flesh were sent by Zenker to 
Professor Virchow at Berlin. He fed a rabbit with some of it, and this 
rabbit died about a month after the feeding, with symptoms of general muscular 
paralysis, and myriads of young Trichinae were seen in its muscles. Other 
rabbits were fed with the flesh of the first rabbit, and they too died with 
similar phenomena. 

Virchow found the villi of the intestines of the rabbits loaded with the ova 
or prospermice of the entozoa ; and he found mature Trichince of both sexes 
moving freely in the mucus of the intestine. The males were filled with 
sperm corpuscles, while the females were densely stocked with ova and their 
germs, and with young ones in the eggs, coiled up like little snakes. 

Another observer had before made similar experiments. Herbst, in 1852, 
fed three young dogs with the flesh of a badger whose muscles were saturated 
with Trichinm. The dogs in their turn became trichinatous; being killed after a 
few, months, the parasites were seen in their flesh. Pigeons also were fed 
with moles' flesh known to be trichinatous; and free Trichinae were found in 
the flesh of the neck, the wings, and the thighs of the pigeons in eighteen days. 
But Herbst did not examine into the relation between the capsuled and the 
free Trichina, as Virchow and Zenker have done. 

The Trichina spiralis is now well known not to be limited to the muscles of 
man. It occurs in eels, cats, dogs, badgers, hedgehogs, pigeons, moles, and 
swine. It has been found in the horse, ox, sheep, and other ruminants; also 
in rabbits, rats, mice, and guinea pigs fed with trichinous flesh. Thus the 

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EXPERIMENTS WITH THE TRICHINA SPIRALIS. 157 

debris of an animal eaten by carnivora may become fatal to rodents, or a car- 
cass near a marsh or rivulet may communicate the parasites to man or ani- 
mals drinking such water (Devaine). 

In the summer of 1860, a subject was received into the dissecting-room of 
the University of Edinburgh; and the muscles of that subject contained 
numerous flesh-worms. Dr. Turner (then Demonstrator of Anatomy, and 
now Professor) took the opportunity of verifying the experiments of the Ger^ 
man professors. He fed kittens with portions of the human flesh containing 
the worms, which were observed to move, though somewhat languidly, on 
rupturing the cysts. To one cat, on the 7th, 13th, and 16th of. July, he gave 
portions of the flesh, and in the intervals fed it on bread, milk, and fish. He 
killed the cat on the 24tli of the month. Nothing could be seen with the 
naked eye in the fluid of the small intestines ; but on placing a drop below 
the microscope, thread-like worms were seen actively moving about in it, or 
coiling themselves up in a spiral form. Every drop of fluid taken contained 
one or more. Each of these thread-like worms was about ^j'^th of an inch 
long, and -,-^^0*^ of ^^ ii'ch broad, with a pointed and a rounded end, and 
about two-thirds smaller than the mature flesh-worms met with in the muscles 
of the cat. These had migrated from the intestines, and after working their 
way between the fibres of the muscles, had become encapsulated — the cap- 
sules being perfectly transparent. Herbst and Virchow have found the flesh- 
worms both in the mesenteric glands and in the mesentery, and therefore, 
presumably, in transitu between the intestines and the muscles. All the 
phenomena described occurred within the space of a single month ; and even 
as early as three weeks after feeding, Virchow found the young brood equal 
in size to those administered at the commencement. The genesis, develop- 
ment, and migrations of these flesh-worms are thus proven to be astonishingly 
rapid. Dr. Thudichum has also very recently verified these experiments ; 
and at the conversazione of the British Medical Association, held at Downing 
College, Cambridge, on 4th August, 1864, he exhibited the parasite, 
living, in various stages of development, which he obtained from the muscle 
of a rabbit infested with them, and also from some pork chops (Brit. Med. 
Journal, August 13, 1864). 

Thus the T. spiralis has been shown to be a bisexual parasite, producing 
its young alive in the intestines of the animal whose muscles it may infest. 
So long as it remains in the capsule, it is immature and non-sexual, and so 
far they are harmless. 

In the mucus of the intestines the mature TrichincB find a suitable place for 
growth and breeding, their progeny finding their way to the muscles, where 
they eventually become encysted ; and their favorite haunt there seems to be 
the small muscles of the larynx (Zenker). According to Virchow's conclu- 
sive testimony, all these phenomena occur within the space of a single month; 
and, in his experiments, even as early as three weeks after ingestion, the young 
were found to equal in size those that he administered at the commencement ; 
but even in the seventh and eighth week, living Trichince have been found in 
the intestines, filled with eggs and embryos, rendering it not improbable that 
the intestinal Trichince bear young repeatedly, which pass into the muscles at 
difierent times ; hence also the exacerbations of the disease. The genesis and 
migrations of Triehinm are therefore astonishingly rapid, and probably with- 
out parallel in this class of parasites (Cobbold). 

Since the discovery by Leuckart of the round worm, of which the T. spiralis 
is the immature condition, since the case recorded by Zenker, and since the 
more complete knowledge that has been acquired by experiments of the won- 
derful migrations of the young Trichince, attention has been especially 
directed to the possibility of the triehinatous disease in man being much more 
common than was anticipated. In December, 1860, Professor Wunderlich 
met with a ease of prolonged fever, which did not correspond in its course 

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158 TOPICS RELATIVE TO PATHOLOGY. 

with any of the well-known specific fevers. The patient was a butcher. He 
eventually got quite well, and so far negatived the diagnosis of acute tuber- 
culosis which had been made. A second butcher, from the same establish- 
ment, came into the hospital with the same symptoms of high fever, with 
immense depression ; but the course of the disease again did not correspond 
with any of the known fevers. Here, as in the first case, the muscles were 
particularly implicated, but in a less degree. There was not only muscular 
pains, but absolute soreness of the muscles on pressure. This man, too, 
eventually got well. A third and a fourth butcher, from the same house, 
were also taken ill with similar severe febrile symptoms, but they were not 
seen by Wunderlich. 

These men had been killing a number of pigs ; and, as is the custom, they 
ate of the raw flesh. Eight men so ate, and four of them were afterwards 
attacked with these anomalous but severe febrile symptoms. Unfortunately 
none of the pork had been preserved, and the possibility of IHehince existing 
in it had therefore not been proven. Moreover, none of these men died, and 
no evidence of the parasite existing in their muscles was obtainable. But 
looking to the undoubted fact that the use of the raw meat brought on the 
disease, and to the great probability that the wanderings in large numbers of 
the Trichinas, will produce these symptoms, Professor Wunderlich deems him- 
self justified in thinking that there are some grounds for considering these 
febrile attacks to have been due to triehinatous disease. That individuals 
enjoy good health, although the muscles are infested with the encapsuled 
Trichince, is now well known, from the number of cases that have been seen 
in dissecting-rooms. Cases are also referred to by Mr. Curling, of its being 
recognized in the muscles of men killed by accident, when engaged in severe 
manual labor (London Med. Gazette, Jan., 1838; also Turner, in Edin. Med. 
and Surg. Journal, 1860, p. 209). The distinguished teacher of clinical sur- 
gery at Berlin, Professor Langenbeck, related to the Medical Society there, 
in 1863, the case of a man from whom he had recently removed an epithelial 
cancer situated in the neck. During the operation, the platysma myoides 
exhibited a singular appearance, which, on careful inspection, was found to 
arise from the presence in the muscle of innumerable dead IHehince, con- 
tained in calcified capsules. On inquiry, the following facts were elicited: 
In the year 1845 there was a "church visitation" (whatever that may mean, 
and it seems to imply some jovial meeting), in which eight persons took part, 
and of these, seven afterwards sat down to a breakfast consisting of ham, 
sausages, cheese, roast veal, and white wine. In the course of three or four 
days every one of the seven persons was seized with diarrhoea, pains in the 
neck, oedema of the face and extremities. Of the seven, four died, and the 
three who survived (among whom was the man operated upon eighteen years 
afterwards by Professor Langenbeck), remained ill for long afterwards. The 
suspicion arose that poisoning, through the agency of white wine, had taken 
place; and an investigation was made, but without any result. The innkeeper, 
however, at whose house the breakfast was given, being still under suspicion, 
was obliged to give up his business and emigrate. The importance of such a 
case in its forensic aspects cannot be overrated; and it becomes an important 
subject of inquiry whether some of our cases of death from suspected but un- 
proved poisoning may not be due to trichina disease, which is now known to 
be much more prevalent than has hitherto been supposed, both in this country 
and in Germany. 

Very recently attention has been again awakened on the subject by an 
occurrence almost tragical. About the middle of October, 1863, there was a 
festive celebration at Heltstadt, a small country town in Prussia, near the 
Hartz Mountains, numbering from 5000 to 6000 inhabitants. One hundred 
and three persons sat down to an apparently excellent dinner, mostly men 
in the prime of life. Within a month more than twenty persons had died, 



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OCCURRENCE OF TRICHINA SPIRALIS IN MAN. 159 

and more than eighty persons were then suffering from the fearful malady, 
while those who were apparently unscathed were in hourly fear of an outbreak 
of the encapsuled flesh-worms. The dinner had been ordered at a hotel, and 
it was arranged that the introduction to the third course should consist of 
" Rostewurst." The sausage-meat was therefore ordered at the butcher's the 
necessary number of days beforehand, in order to allow of its being properly 
smoked. The butcher, on his part, went to a neighboring proprietor of pigs, 
and bought one of two pigs from the steward of the pig-farm. The steward 
unfortunately sold a pig which his master intended should not be sold, because 
it was not considered to be in good condition. Nevertheless, for this time, at 
least, the 'butcher got "the wrong sow by the ear." The ill-conditioned pig 
was the one that was killed and worked up into sausages. These were duly 
smoked and delivered at the hotel; and after being toasted before the fire (so 
as to be warmed through merely), they were served to the guests at the 
dinner-table. 

On the day after, several persons who had eaten the dinner were attacked 
with great irritation of the bowels, loss of appetite, great prostration, and 
fever. The' number of persons attacked rapidly increased; so much so, that 
great alarm was felt in so small a town lest an epidemic of typhoid fever was 
about to set in. But one of the physicians at last conjectured that some 
poison must be at the bottom of the outbreak, and an active inquiry into all 
the circumstances of the dinner was instituted ; and when the muscles of the 
calves of the legs of some of the sufferers began to be affected, the description 
of Zenker's case (already described, pp. 155, 156, ante) was at once remem- 
bered. The remnants of sausages, and of pork employed in the manufacture 
of them, were examined with the microscope, and found to be literally swarm- 
ing with encapsuled flesh-worms. From the muscles of several of the suffer- 
ing victims small pieces were excised, and under the microscope they were 
seen to be charged with Trichince in all stages of development. It could 
therefore no longer be doubted that as many of the 103 persons as had dined 
together and partaken of the "Rostewurst" were affected with trichinous dis- 
ease by eating the trichinous pork, the flesh- worms of which had not been 
killed by the smoking and toasting. On the contrary, the subdued heat of 
toasting would rather foster their vitality. 

This catastrophe awakened sympathy and fear throughout the whole of 
Germany. Most of the leading physicians were consulted in .the interest of 
the sufferers ; and some visited the neighborhood where most of the affected 
patients were. None could bring relief or cure. Case after case died a slow 
and lingering death, by exhaustion from nervous irritation, fever, loss of muscu- 
lar power, inflammation of the lungs, or of organs essential to life. The cases 
have been observed with great care and chronicled with skill. All the fea- 
tures of the remarkable disease have been registered in such a manner that 
hereafter there can be no difiiculty in recognizing the disorder. 

The disease begins a few days after eating the meat in which there were 
Trichince, with loss of appetite, general discomfort after eating, irritation of 
the stomach, vomiting, and diarrhcea. These symptoms last from four to 
eight days, till the progeny are born. Severer symptoms may set in, and 
continue till the parasites are encapsuled, if not previously fatal. These 
symptoms are, — <3outinued. diarrhoea and fever ; oedema of the eyelids ; also 
pain, or at least painful sensation of weakness in the limbs ; oedema of the 
joints, sometimes of the whole body; difiiculty in moving the tongue; profuse 
clammy perspiration ; and those patients who do not become convalescent die 
either unconscious, with symptoms of typhoid fever, or, in a few cases, remain 
conscious to the end, complaining of inability to breathe freely. The suf- 
ferer generally lies on his back, with his legs drawn up, unable to move or 
speak. The only important symptom of typhoid fever said to be absent in 
the disease is the enlargement of the spleen ; and it is very probable that 



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160 TOPICS RELATIVE TO PATHOLOGY. 

some of the so-called epidemics of typhoid fever in former days were caused 
by the propagation of TrichiruB in the human body. But the epistaxis, the 
pains and gurgling on pressure in the right iliac region, the rose-colored erup- 
tion, characteristic of typhoid fever, cannot exist in trichinous disease ; while 
the earlier irritation of the stomach and bowels, with oedema of the face and 
severe muscular pains, especially on motion, with breathlessness increasing to 
dyspncea, or almost asphyxia, ought to render the parasitic disease easy of 
diagnosis from enteric fever. Pneumonia or peritonitis may be suddenly fatal 
in mild cases. 

Since the disease has become better known, a great many cases have been 
observed in Germany, and several cases in the United States. On this sub- 
ject, Dr. Clymer records, in the second American edition of my book, that — 

"In 1859, 1860, and particularly in 1862, many cases were noticed at 
Blankenbourg, chiefly amongst the soldiers. In 1862, of 60 attacked, 2 died 
(ScHOLz). Two cases were seen by Wunderlich in Leipsic in 1861 ; and 
Wagner describes 5 eases which occurred there in 1863 {Archiv. der Heil- 
kunde, 1854). Landois met with 12 cases in the island of Riigen in 1861, 
and Wentzel with 20. In that year, at Cosbach, 3 persons of the same 
family, who • had eaten of fresh pork, and in whose muscles Zenker found 
trichinae, were affected. In the same year, 300 fell ill with the disorder in 
Magdebourg, and 2 died. In the summer of 1862, at Calbe, 30 persons, in a 
population of 1200, were attacked — 9 males, 25 women and 4 children; and 
8 died — 1 male, 6 women, and 1 child. In the spring of 1862 there was an 
outbreak at Plauen, in Saxony, and several died (Bohler). In the autumn 
of 1863 the Heltstadt epidemic occurred, already described. There was an 
outbreak at Hedersleben in 1865 (300 cases and 40 deaths) ; at Zittau, in 
1866 (57 cases) ; and at Gorlitz (80 cases and 1 death). 

" But few cases of the trichinous disease have been recognized in the United 
States. The first cases reported are believed to be those of Dr. Joseph Schnet- 
ter, of New York ; 2 cases after eating underdone pork-steaks ; neither were 
fatal (January, 1864) ; and 5 eases and 1 death (February, 1864), of persons 
who had eaten raw ham, in which trichiase were subsequently found.* About 
the same time. Dr. Voss, of New York, had 4 cases on board one of the Bre- 
men steamers, then in the harbor. Dr. Voss verified his diagnosis by cutting 
down on the deltoid muscle of one of the affected persons, and removing a 
portion for microscopical examination ; it proved to be filled with trichinse.f 
Dr. J. R. Lothrop, of Buffalo, has reported a case.| Nine cases have hap- 
pened in 1866 in one family at Marion, Iowa, and been reported by Dr. 
Joseph H. Wilson.§ About the 5th of May, six persons in the family of Mr. 
Bemiss, of that place, were taken ill, with the characteristic symptoms of the 
trichinous disease, which was not, however, at first recognized, and the disorder 
was looked upon and treated as typhoid fever. On the 14th of May, three 
other members of the family became similarly affected. It appeared that 
towards the end of April a couple of smoked hams had been bought, and 
from that time until the 5th of May all the nine had eaten of it sliced raw, 
and all had been taken ill in from five to ten days. Five of the nine died. 
Two post-mortem examinations were made, and trichinse were found in large 
numbers, and very active, in the muscles, in the lungs, and spleen. All the 
organs appeared healthy to the eye. It is stated that one of the family ate 
some of the meat 'rarely done,' and was affected but slightly, and another, 

* Observations on Trichina Spiralis, by John C. Dalton, M.D. The Transactions 
of the New York Aoaderiiy of Medicine, vol. iii, 1864. 
•)■ Dalton, I. c. 

I ATreatiseon the Principles and Practice of Medicine, by Austin Flint, M.D., 1866. 
I St. Louis Medical Reporter, July 15, 1866 ; Chicago Medical Journal, August, 1866 



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CASES OF TRICHINA SPIRALIS IN THE UNITED STATES. 161 

when well cooked, who was unaffected. No portion of the offending ham was 
got for examination ; but it was shown that some of it had been given to a 
healthy sow, who died on the 1st of June, ' with all the symptoms of hog- 
cholera ; and on some of her meat being examined, it was found swarming 
with trichinse.' Dr. H. Ristine, of Marion, Iowa, has also reported six cases,* 
happening in the same country, in four families living in the same neighbor- 
hood, all children, their ages ranging from seven to seventeen years. It 
appears that on the 25th of April, 1866, they had all eaten chips of raw 
ham. ' On the 27th they were, most of them, seized with diarrhcea, followed 
in two or three days by the other characteristic symptoms. In the oldest 
girl the order of succession was reversed, the muscular pains preceding the 
diarrhoea.' The ' counterpart of the eaten ham, put up in brine, was examined 
and found to contain trichinous cysts.' The same meat, it is stated, was eaten 
by the family of the owner, when well cooked, and with no bad effects. We 
have no data at present to estimate the degree of prevalence of trichinous 
disease amongst the hogs of this country. 

" The symptoms of the disorder in the pig are said to be loss of appetite, a 
hoarse voice, and aversion to movement, particularly to running ; and when 
this is attempted there is dragging of the extremities (Cobbold). Still it is 
positively asserted that the animal may be infested, and yet show no signs. 
Cobbold mentions an instance where a pig appeared remarkably healthy, and 
yet the butcher who ate his flesh died of the disease. Delpech says, in his 
Report to the French Government : ' It is rare that any symptoms are spon- 
taneously developed in the infected animal which would lead to any suspicion 
of the disorder : it has the appearance of perfect health. The butchered 
meat, too, looks well.'t Dr. H. Jardine states (foe. cit.) that, in his vicinity, 
the opinion prevails that the trichina spiralis exists in the flesh of animals 
affected with hog-cholera, the symptoms of this disorder being diarrhcea, 
swelling of the neck, stiffness of the limbs, debility, and cough ; but the 
opinion has not been yet verified by microscopic examination. 

"The Chicago Academy of Sciences appointed in the spring of 1866 a com- 
,mittee of physicians, 'to examine into the facts concerning the supposed 
existence of trichinse in pork raised in this country.' The results of their 
well-conducted observations were, that having procured and examined por- 
tions of muscles taken from 1394 hogs in the different packing-houses and 
butcher-stalls of Chicago, they found trichinaj in the muscles of twenty-eight 
hogs ; from which they conclude, that in the hogs brought to that city, 1 in 
50 is affected with trichiniasis in a greater or less degree ; which would indi- 
cate that trichiniasis in pork is even more common in this country, or in that 
of the Northwestern States, than in Germany. In the town of IBrunswick, 
North Germany, where a most careful inspection of 19,747 hogs was made in 
the years 1864-65, only two were found to have trichinse in their muscles ; 
'the proportion being 1.10000 to 1.50 in the Chicago pork. 'J One of the 
tables of the Chicago committee shows the great variation in the number of 
helminthes infesting the several muscles examined. An approximation only 
to the number existing in a cubic inch of a given muscle could be obtained. 
The method adopted was to count the trichinse existing in several different 
portions of a muscle, each a cubic jgth of an inch in size, and to multiply 
the average number to a cubic inch. Of twenty-eight specimens examined 
with this view, only three of them contained over 10,000 to the cubic inch, — 
18,000, 16,000, and 15,000 respectively. The remaining twenty-five were 
infested to a much less degree — from 48 to 6000 in the cubic inch. It was 

* The Medical Record, New York, August 6, 1866. 

f See the Report officially made to the French Minister of Commerce by MM. Del- 
pech and Raynal, Bulletin des Academic de Medecine, May, 1866 
i Chicago Medical Examiner, April, 1866. 

VOL. I. 11 

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162 TOPICS RELATIVE TO PATHOLOGY. 

calculated that a person eating an ordinary meal of the pork from which the 
specimen containing 18,000 to the cubic inch was taken, would soon become 
infested with not less than 1,000,000 of young trichinse* 

" With regard to the muscles of the hog which are the most common site of 
trichin», the observations of the Chicago committee do not agree with those 
of European observers. In Germ9,ny, the inspectors of pork are instructed 
to examine microscopically nine different sets of muscles, — ^namely, those of 
the diaphragm, tenderloin, shoulder, front and back of neck, extensors of the 
fore-arm, flexors of the leg, and the ipuscles of the larynx. In the trichinous- 
infested muscles examined by the Chicago committee, more than one-half 
were spinal muscles, which are not named in the German list. 

" In conducting an examination of the trichinatous pork, the tendinous 
extremities of muscles should be selected, as here they are usually most 
numerous. The cysts are visible to the naked eye as whitish, round, or ovoid 
specks, sprinkling the surface of the muscle. If a very small piece of muscle 
is cut off with scissors, and then torn in shreds with a needle, freeing the cysts 
from the flesh, and these are touched with a drop of hydrochloric acid, the 
lime is dissolved and the white coloring disappears ; or a piece of the sus- 
pected flesh may be put into a watch-glass with liquor potasse (1 part to 8 of 
water), when it becomes changed to a mucus-like, clear mass, and the cap- 
sules will be seen as sharply defined minute white specks (Leuckabt). But 
it is always better, if possible, to use the microscope, and trichinae not yet 
encysted can only be recognized by the microscope. A thin layer of the sus- 
pected flesh should be cut out with a sharp knife, and spread over a glass 
plate, moistened with a drop of water, covered with a thin piece of glass, and 
examined by a magnifying power of 50. Their intimate structure cannot be 
recognized with a less power than 200 (ALTHAUS)."f 

The vitality of the Trichince is not destroyed in the meat or in other sub- 
stances, such as sausages, in which they may be located, below the tempera- 
ture of boiling water ; and it is fully proved that if subjected for a sufficient 
time to insure that every particle has been acted upon by that degree of heat, 
they are found incapable of further development, and are, in fact, destroyed. 
Salting, smoking, and toasting trichinous meat, as is usually done, does not 
appear to be sufficient to destroy the worms in all parts of the meat. 

Picric acid (acidum picro-nitrieimi) has failed. In trichinous pork of a pig 
killed with picric acid the worms were found alive (W. Mullee, of Hom- 
berg). Benzine, too, has failed. 

Carbolic add has also been recommended ; and any of these may kill or 
render the parasite inert if it is still in the stomach ; but if its progeny have 
bred, and commenced to penetrate the tissues, nothing seems able to remedy 
the 6vil till the parasite becomes encapsuled. A few doses of calomel and 
castor oil repeated occasionally, even although diarrhoea may be present, is 
advised by Ruprecht to remove intestinal Trichince. He also recommends 
wet-sheet packing, to relieve the sleeplessness and the copious sweats. 

When this flesh-worm was seen more than thirty years ago, it was little 
thought that the bit of muscle sent to Owen contained the germs of a disease 

* As many as 2,000,000 trichinae have been estimated in the muscles of a man who 
died of the disorder ; and Prof. Dalton counted in a piece of muscle (in one of Dr. 
Schnetter's cases) ^\th of an inch square, and ^^th of an inch thick, where they were 
in average abundance, twelve trichinae, which would give in round numbers over 
85,000 to the cubic inch ; and in the portion of inusclft taken from the living subject, 
in Dr. Voss's case, they numbered a little over 7000 to the cubic inch (Dalton, I. c). 
In one of Dr. Wilson's cases, which proved fatal, 104 trichinas were counted in'a piece 
of the rectus femoris muscle measuring -jJ^th of an inch square, and Jjth of an inch 
thick, which would give nearly 180,000 to the cubic inch (Clymer). 

f On Poisoning by Diseased Pork; being an Essay on Trichinosis or Flesh-worm 
Disease; its Prevention and Cure. By Julius Althaus, M.D. London, 1866. 

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DESCRIPTION OF GUINEA -WORM. 



163 



which might be carried in a living pig from Valparaiso to Hamburg, and 
then kill almost the entire crew of a merchant vessel. It has been recently- 
related that a pig so diseased was shipped at Valparaiso, and killed a few 
days before arrival at Hamburg. Most of the sailors ate of the pork in one 
form or another. Several were affected with the flesh-worm, and died. One 
only escaped being ill. Numerous cases of fever, and epidemics of inscruta- 
ble peculiarity, are now claimed by medical writers, with much show of 
reason, as outbreaks of the flesh-worm disease. 

_ Professor Eckhardt, of Giessen, has obtained permission to produce the 
disease in a criminal condemned to die, and to try various remedies on him. 
(For a very interesting account of Trichinoua or Flesh-worm disease, the 
reader is referred to the recent work of Dr. Althaus on this subject.) 

For the diagnosis' of Trichince in the muscles of man, Kuchenmeister has 
proposed to harpoon the muscles; but this seems a very severe operation. 
Welcker believes that the best place to look for them is under the tongue, 
close to the frsenum : in cats they can be easily seen in this situation. 
Whether it is so in man is not yet known (Virchow's Archiv., 1861, p. 453, 
quoted by Dr. Parkes, 1. c). 

5. The Filaria medinensis, commonly called Guinea-worm, or Dracunculus, 
livesamongst the connective tissue of man and of some animals. In this situa- 
tion it is only known as a female, containing in its germinal sac an enormous 
quantity of young Filaria, and resembles a long piece of uniformly thick 
white whip-cord. In this country few are familiar with its appearance, or 
with the lesions it produces ; and we therefore look for our knowledge regard- 
ing the main points in the natural history of this parasite to be furnished to 
us by observers in Africa or Asia ; who we hope will fill up the gaps which 
still exist. 

The Guinea-worm is essentially a tropical parasite. It is endemic in the 
hot intertropical regions of Asia and Africa, extending from Egypt, about 23° 
or 24° north latitude, to Sumatra and adjacent islands, as far as 10° or 12° 
south. But it is only in some districts within these tropical limits that the 
parasite abounds. For example, it is endemic in Arabia Petrea, the borders 
of the Persian Gulf and of the Caspian Sea, the banks of the Ganges, Upper 
Egypt, Abyssinia, and Guinea. Its occurrence in Guinea (although it has its 
common name from this place) is extremely capricious. In some districts 
every native who comes off to the ships seems to be affected by it ; in other 
places in Guinea it is very rarely seen. 

The F. medinensis is unknown in America, unless the person in whom it 
exists has been in the places where the Dracunculus is endemic. The only 
exception is the Island of Cura9ao. It is sometimes so extensively dissemi- 
nated that it has been said to prevail after the manner of an epidemic. 

Although this parasite rarely causes death, still it is often the cause of 
great distress and loss of strength to regiments quartered in those places where 
it is epidemic. 

In the Statistical Sanitary and Medical Reports of the Army Medical Depart- 
ment for 1860, the admissions for Dracunculus into the hospital may be shown 
as follows : 

I.— EUROPEANS. 



stations. 


Average Strength. 


Total Admissions. 


Ratio per 1000. 


Home Stations,* . . 
Mauritius, . . . . 

Bengal, 

Madras, . . . . . 
Bombay, 


97,703 
1,886 
42,371 
10,696 
11,388 


28 
17 
51 
19 
114 


.3 

9.0 

1.2 

1.7 

10.0 



* It is of course to be inferred that these men had served abroad in countries where 
Dracunculus is endemic. 

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164 TOPICS RELATIVE TO PATHOLOGY. 

II.— BLACK TKOOPS AND ASIATICS. 



Stations. 


Average Strength. 


Total Admissions. 


Eatio per 1000. 


Sierra Leone, . . . 

Gold Coast, 

^outh China, . . . 


379 

313 

2611 


1 

77 
73 


26 

246 

26.0 



In India, the average number of days which those affected with the Guinea- 
worm remain in hospital increases progressively with advancing years. During 
the first period of life (18 and under 20 years of age), the average number of 
days under treatment — during which period each person was rendered ineffec- 
tive — was 14.8 ; during the second period (20 and under 25 years), it was 
16.188 days ; during the third period (25 and under 30 years), it was 18.001 
days ; during the fourth period (30 and under 35 years), it was 22.718 days ; 
during the- fifth period (35 and under 40 years), it was 24.290 days; during 
the sixth period (40 and under 45 years), it was 31.620 days (Ewart). 

Dr. Leith, in the Bombay Mortuary Reports, records 133 deaths from Dror 
eunculus in eight years (from 1848 to 1857). A fatal result generally takes 
place from hectic (Loeimee) and exhaustion, consequent on the copious dis- 
charges which sometimes follow the presence of the parasite, or from abscesses 
forming and bursting into the abdominal cavity (Ewaet). Death has fol- 
lowed from tetanus (Drs. Minas and McKenzie, Trans, of Hydrabad Med. and 
Phil. Society). Great destruction of tissues sometimes results from sloughing ; 
and deep-seated inflammation may attend its existence, with the formation of 
abscesses and deep-seated sinuses. The death of one person is recorded by 
Dr. Minas at Sirsa, in whom the whole body and skin was a network of 
Guinea-worms. As a rule, however, the patient is unconscious of the presence 
of the Dracunculus till it is matured and ready to make its exit. 

The Number of Worms observed in any one individual is very various. In the 
rnajority of cases only one is present, or known to be making its exit at one 
time. But there are remarkable exceptions to this rule. Mr. Forbes men- 
tions that most of those affected have had two worms extracted ; but many 
have had four, five, and six ; and when he wrote he was then treating a man 
in hospital in whom no less than fifteen were exposed to view, and many of 
these were extracted. Dr. A. Farre mentions that as many as fifty worms 
have been met with in one person. Such cases, however, are confessedly rare 
even in India, where fifteen worms is about the greatest number observed. 

Seat or Locality of the Parasite. — The lower extremities are by far the most 
frequently affected — or rather, the parasite most frequently tends to make its 
exit there ;— 98.95 per cent, of the parasites do so. Two cases are recorded 
by Lorimer, remarkable in this respect, that one gave vent to seven and the 
other to thirteen parasites. In the case where seven parasites were extracted, 
two were from the left foot, three from the left leg, one from the right leg, and 
one from the left forearm. In the case where thirteen parasites were extracted, 
four were taken from the left foot, two from the right foot, two from the left 
leg, one from the right leg, one from the right thigh, and three from the right 
forearm. 

The Dracunculus has made its appearance in the socket of the eye, in the 
mouth, m the cheeks, and below the tongue (Scott). Dubois records its exit 
from the nose, the ears, and the eyelids. Dr. Kennedy records cases in which 
the parasite made itself apparent in the back and muscles of the loins One 
preparation exists in the Museum of the Army Medical Department, in which 
a great number were removed from beneath the scalp. Instances are recorded 
m which the worm has been found in the internal viscera. All such cases 
are regarded as extremely rare. It is of importance to notice, however, that 

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GUINEA -WORM IN HORSES AND DOGS. 165 

both Dr. Scott and Dr. Van Someran agree in stating that the men who 
carry water in India, in leathern bags on their back, are infested by the Bra- 
cuncuhts on all that part of the skin that has often been wetted ; while Drs. 
Qhisholm and Scott state that the legs of persons who walk among grass 
(especially during the rainy season, and particularly gardeners and agricul- 
turists, and those who are obliged to wet themselves frequently) are at all 
seasons liable to Dracumculi. Some animals are said to be affected by the 
parasite. Forbes says that horses and dogs are so affected, and relates that a 
"tatoo" (a small Indian horse) was exhibited at Dharwar, having a Dra- 
cuneulus protruding from its right hind fetlock. The parasite was of the 
usual size, and made its appearance as a boil; and no difference could be 
perceived in any respect in it from the Drammeulus which infests man. Clot 
Bey remarks that dogs are also sufferers; but on this head information is 
greatly to be desired. Assistant Surgeon Adam Taylor, of the 1st Goorkha 
Light Infantry, wrote me from Bootan, in 1866, that during the rains of 
August, 1862, he being in medical charge at Hissar, a sandy district about 
seventy miles from the desert of India, he saw a favorite bull-terrier with 
swollen feet. From a fluctuating tumor in one of the hind feet he liberated 
four ounces of serum, and eighteen inches of a Guinea-worm; four inches 
more the next day; and the remainder, about iifteen inches, was wheedled 
out by a native barber the following day. The worm was exactly the same 
as those found in man ; and he has repeatedly seen Dracunculus in horses, 
and heard of their existence in camels. He believes the habitat of the para- 
site is sandy soils and not water. 

Migratory Powers exhibited by the Guinea-worm before Extraction. — Dr. 
Smyttan relates the cases of two officers, in one of whom the Dracunculus 
could be felt, and traced with the fingers like a cord under the skin at the top 
of the shoulder. By and by it made its way to the elbow, where it was 
equally distinct ; and in a few weeks it gradually worked its way to the wrist, 
whence it was extracted. In the other case the Guinea-worm was observed 
under the skin inside the biceps, and about the middle of the upper arm. It 
then passed round the elbow-joint and down to the middle of the forearm, 
then back to the region of the inner condyle of the humerus, whence it was 
extracted. It was three months engaged in this migration. Dr. Baton 
records similar cases {Edin. Med. and Surg. Journal, 1806, vol. ii, p. 151) ; 
and Dr. Morehead says of his men, that when they had felt the Guinea-worm 
in the thigh, in the first instance, it had subsequently been ejected from the 
foot. He has distinctly noticed the corded feeling of the worm below the 
skin, and observed that it was entirely gone the next day he examined the 
part. Dr. L. W. Stewart, of the Madras Medical Service, relates a very dis- 
tressing instance of this kind which happened to an officer, from whose scro- 
tum a Guinea-worm fifteen inches long had already been extracted. Ten 
days afterwards he experienced an unpleasant sensation in the posterior 
aspect of the left thigh. Day by day the sensation shifted lower down, till it 
reached the popliteal space. A few days later the sensation was experienced 
in the calf. Hitherto nothing was visible; but at the end of sixteen days 
from the first sensation in the thigh, the convolutions of a Guinea-worm could 
be distinctly traced at the outer side of the ankle-joint. Dr. Stewart now 
wished to cut down and extract the parasite, but the evening was too dark, 
and he delayed till the following morning. By the morning visit, however, 
the parasite had again fled, and had taken up a position in the deeper muscles 
of the foot. Not a trace of the worm could be recognized in the place which 
he had evacuated. Many abscesses now formed, and severe inflammation of 
the foot resulted, which confined the patient for three months before he was 
free of this wandering parasite. Dr. Ewart says he has seen the worm change 
its position from the upper part of the lateral aspect of the thorax to the 



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TOPICS RELATIVE TO PATHOLOGY. 



groin in the course of twenty-four hours ; but he has never seen the creature 
travel from below upwards {Indian Annak, vol. vi, p. 490, July, 1859j. 

Structure of tJie Di'acuncuius. — It is often a matter of extreme difficulty to 
extract the whole worm without breaking it, and on account of its remarkable 
elasticity (for it may be extended to twice its apparently natural length), 
good measurements of any large number of worms are not easily obtained 
(Busk). Of forty Indian specimens, Ewart gives the average length at 25.25 
inches, the shortest being 12| inches, the longest 40 inches. Clot Bej' records 
their length at from 6 inches to 4 feet, in Egypt. Carter gives their dimen- 
sions in India at about 28 inches long, -Jth of an inch in diameter. He has 
dissected five. Busk gives the dimensions at from 4 to 6 feet, and y'^th of an 
inch in diameter ; and he has made out that it grows in 
^^°- ^^- the human areolar tissue at the rate of about an inch a 

week. 

H. C. Bastian, Professor of Pathology, University 
College, has recentlj^ read an account of the anatomy 
of this parasite at the Linnsean Society ; and from the 
records of these excellent observers we have now a very 
complete account of the anatomy of the Guinea-worm. 
The anterior end of the worm (Fig. 15) may be recog- 




I)ia,i,'rara of the head or 
anterior end of the Guinea- 
worm ; showing (a) Puncti- 
form mouth l-2J00th of an 
inch in diameter; (?j.i Upper 
large papillae ; (c.) One of 
small lateral papillje ; (d.) 
One of four crucial white 
lines meeting at the month, 
and occupying intermuscu- 
lar spaces (H. (J. Bastian). 



nized by a "punctum" in its centre, -ji/onth of an inch 



in diameter, surrounded by rugae in circles, the external 
of which was ^^j of an inch in diameter. Above and 
below are two papillae opposite each other, with a trans- 
parent area iu the centre of each. These are rather 
oval, ^f5-th of an inch in diameter, with a transparent 
area of jTrooth of an inch. Besides these, two lateral 
tubercles exist, much smaller, more indistinct, and farther from the punctum 
than tlie upper and lower papillas. They are Tp\,T7th of an inch in diameter. 
It is difficult to obtain a good view of the head ; for, as it is the first part 
to protrude through the skin, it is usually rubbed off" or destroyed by the 
treatment adopted for extraction. 

Great varieties in form are presented by the tail or posterior end of the 
worm^ (Fig. 16). The remains of the attenuated extremity of the young 
Filaria, being more or less persistent in the form of a hook or spikelet, was 

Fig. 16. 




Various forms of the caudal end of the Guinea-worm: (a, b, c.) After Busk— all of them proligerous- 
(D.) After Oaetee; (B.) After GuEENllow. 

believed at one time to be the penis of a male; and such specimens as showed 
such spikelets have been mistaken for male Guinea-worms. All these forms, 
as Busk showed, have been found iu specimens containing living young ones 
(proligerous). All are females that have yet been found, and no males are 
known to exist in the human body. The strengtli of the tissue of the Dra- 
cuncidm is such that a loop of the parasite will suspend a weight of llf 
ounces (Scott), and it is elastic to a remarkable degree. On opening the 
body, two longitudinal muscular bands are seen on the dorsal, and two on the 



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STRUCTURE OF THE GUINEA -AVOKM. 



167 



ventral aspect, nmniiig from end to end ; while circular or transverse rugre 
mark the whole extent of the worm ; and these are approximated or apart "as 
the worm is contracted or extended. The body of the worm (Fig. 17 ) contains 
an alimentary canal, which commences at the' " punctum" and' terminates in 
the concavity of the tail end. It is of a yellow color, nearly uniform in size 
throughout its extent, and in its course through the body winds several times 
round the genital tube (Bastian). No outlet has yet" been detected. It is 
distinct from the tube containing the young (Forbes). 

The genital organs consist of a large uterine sac or tube, occupying nearly 
the whole length of the worm, and terminating abruptly at either extremity 
m a much smaller tube (probably ovarian), about three-quarters of an inch 
m length. No vagina or vulva can be discovered (Bastiax). The whole 
extent of this uterine sac or capsule is crowded with innumerable young, and, 
with the exception of a transparent half inch or so of the worm, the" whole 
extent of the parent seems to be a uferm, a matrix, or a proligerous capsule, 
carrymg a countless offspring, to which no parturient female of any animal 
can be compared for productiveness ; and 

from the fact that no inlet has ever been dis- F'o- i"- Fig. is. 

covered to the genital organs, and from va- a 

rious other circumstances, Mr. Bastian has 
endeavored to show that this innumerable 
progeny has been produced by a process of 
parthoiogenesis similar to that with which we 
are so familiar in the Aphis. 

If a living worm recently extracted be 
well lit up by an argaud lamp, the hair-like 
filaments may be seen in motion with a good 
simple lens ; and if a section be made across 
the parasite after it has been hardened in 
glue, the young may be demonstrated in situ 
(Fig. 19 ). 

When the animal is mature, and present- 
ing its head through the skin, it jwotrudes 
the extremity of the proligerous capsule 
through one of the small jiapillas or puncta, 
carrying forward a prolongation of something 
in the form of a loose corrugated sheath ( Fig. 
18). It gradually assumes the form of a di- 
lated vesicle filled with limpid fluid — the 
contents of the proligerous capsule — contain- 
ing flocculent granular matter and young 
Guinea-worms. Carter tells us that, if kept 
moist, the full-grown parent will live many 
hours ; and in this state the young will live 
till the parent begins to decompose ; and 
when the head end of the worm during its 
extraction may have been dried up for 
several days outside the wound, the remain- 
ing part with the young still remains alive. 
Mr. Busk says that the young survive after 

havmo^ underp;one a considernble de^rree of ^'^^'^^ ovarian tube; (6.) Termination of 
drying up. lliey are exceedingiy numerous, 
and constitute the bulk of the contents of the 
parent's body; but are less numerous towards 
the tail end. Each young one may be said 
to consist of a body and a tail, hair-like and finely pointed. The body con- 
stitutes f ths, and the tail |ths of the whole length. The anterior extremity 




Fig. 17. — .-1. Anteriorextremity ofworm, 

slit open and magnified, showin.L;, {a.) Up- 
per and lower cephalic p:i|iil!i.L- in profile ; 
(6.) Junction qfcesophaiius with intestine, 
and constriction of peritoneal sheath; (c.) 
Anterior termination of uterus, with short 
ovarian tube. B. Po.«iterior extremity of 
worm, slit open and magnified in same 
way, showing its hook-like termination; 
and (a.) Posterior termination of uterus 



intestine (Bastjan). 

Fig. 18. — Anteriorextremity. The ovisac 
(a) is protruded, dilated, and contains 
young: (&.) A funnel-shape sheath sur- 
rounding the protruding ovisac (Green- 
how). 



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TOPICS RELATIVE TO PATHOLOGY. 



has a blunt end, with a rounded oval orifice communicating with a cavity 
occupying about one-half of the whole length of the body, and terminating 
coecally. 

Symptoms of the Q-uinea-worm in the Human Body.—A.s a parasite in the 
human body 'it may be studied during two periods of existence ; but from the 
beginning to the end of its cycle of development its history embraces at least 
three, if not Jour, phases of existence or forms of life: 



A. 





lOOths of an inch X 5 diameters. 



lOOths of an incli X 50 diameters. 



A. Appearance of transverse section of adult Guinea-worm, as seen througliout the greater part of 
its length.— (n, a, a, a.) Sections of tlie/our longitudinal muscles ; ih.) The intestine flattened, and lying 
along the edge of one of the longitudinal muscles; (c.) Walls of the uterine sac, often adherent to the 
parietes of the body. B. Young of the Guinea-worm more or less spirally curved (B-4stianj. 

(1.) During the first period of its existence in the human body the Guinea- 
worm parasite is latent, residing in the connective tissue, at variable depths 
from the surface. During this period it does not exert any irritating influ- 
ence on the surrounding tissue, as has been shown by dissections (Busk). 

(2.) The second period of existence comprehends that of ripening or matu- 
ration of the worm and its progeny, when the worm makes itself felt, and be- 
gins its exit through the skin. This period is marked by characteristic 
symptoms. Drs. Scott, Forbes, Morehead, Lorimer, and Van Someran all 
agree in stating that the earlier symptoms are a pricking, itching heat, which 
is felt at the part where the worm exists, seldom amounting to pain till after 
the lapse of three or four weeks. A small vesicle forms over the part, which 
iitimediately precedes the appearance of the anterior end of the worm. Dr. 
Scott was himself a sufferer, and writes feelingly on this point (see Med.- Chir. 
Review, 182-3). This itching may happen before va\j vesicle forms; and when 
the vesicle forms, it rapidly enlarges — so rapidly that in a few hours it attains 
the size of a good large filbert (Lorimer). If this vesicle is opened earhf, it 
is seen to contain a clear and limpid fluid (the fibrinous serum of irritation ?) ; 
but if untouclied for a day or two, its contents become turbid, and sometimes 
bloody, from the rupture of the proligerous sac, and the discharge of the 
young Filnria amongst the serum. These greatly add to the irritation; so 
much so, that when the cuticle is removed, an angry-looking ulcer is exposed, 
in the centre of which the parasite may be seen presenting itself, with a thin 
transparent tendril about an inch in length hanging from its point. 

After the appearance of the vesicle or blister, it is sometimes weeks before 
the worm protrudes itself. 

The contents of the blister, when turbid, are a discharge from the tube of 
the animal ; as Wilkins, of 4th Light Dragoons, first surmised, and as shown 
afterwards by the independent observations of Forbes, who found that the 
best way to procure the young Guinea-worm for microscopic examination was 
to lay open this vesicle before the delicate membrane of the proligerous cap- 
sule burst. After the escape of the serum from the vesicle, the delicate trans- 
parent membranous tube or eul de me is sometimes protruded from the extrem- 



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PERIOD OF INCUBATION OP THE GUINEA-WORM. 169 

ity of the worm ; and if cold water is gently poured in a constant stream upon 
this protrusion, the dilatation and protrusion increase, till an innumerable 
quantity of young is ejected from the ruptured orifice of the dilated tube. 
Forbes says that he has often repeated this experiment ; and in one instance 
the transparent tube was again retracted within the limb, after three emis- 
sions of young Guinea-worms. On the following day the tube was found 
again protruding as before; and the same result (namely, emission of young) 
followed the gentle application of the stream of water. The animal will emit 
its young daily in this way for some time; and when it ceases to emit them, it 
is then time to begin the extraction of the parasite (Forbes). 

The Period of the Year when Draeunculus is most prevalent seems to vary con- 
siderably in different parts of India, and the probable causes of these diifer- 
ences are of great interest in regard to the origin and spread of this parasitic 
afiection. 

At Madras and its vicinity Guinea-worm annually appears with greater 
prevalence during the hot season (Lobimer), comprehending February, 
March, April, May, and June. At Dharwar and its vicinity the admissions 
to hospital for Guinea-worm generally commence in April and May. At this 
time water is scarce, every tank is dried up, wells yield a scanty supply, and 
the natives are obliged to remain at the bottom of the wells by turns, till the 
required supply is obtained; and when the monsoon sets in (rainy season), 
the admissions gradually increase through June, July, August, and September. 
The increase of the disease amongst soldiers or residents seems to advance • 
with length of residence, generally during the rainy season. In the Bombay 
and Matoongha districts the admissions to hospital begin in May or June 
(irrigation of fields by the natives being common at this time), but it chiefly 
prevails during the rainy months of June, July, August, and September, and 
is rare after October (Smyttan). Dubois, a missionary at Sattimungalum, 
says that its annual endemic prevalence in the Carnatic villages is in Decem- 
ber, January, and February, during which time more than half the inhabi- 
tants are affected. Dr. Morehead's experience at Kirkee and vicinity gave 
March, April, May, June, and July as the months of gradual increase and 
prevalence; and September, October, November, December, and January as 
those of comparative exemption. 

In the Bheel districts Guinea-worm begins to increase in frequency in Feb- 
ruary ; it is four times as frequent in March, and six times as common in April, 
as in February. It reaches the monthly maximum of prevalence in May. It 
prevails to a great extent in June, and continues to be common throughout 
the monsoon months of July and August. During September, October, No- 
vember, December, and January it is least of all prevalent. The half of the 
year comprising the hot and rainy season is, therefore, the period when Dra- 
eunculus abounds, abruptly commencing with the initiation of the former, and 
terminating more abruptly still with the exhaustion of the monsoon in Sep- 
tember (Ewart). 

All the records agree in assigning to this parasite — (1.) An annual periodic 
recurrence; (2.) Periods (annual) of progressive increase and subsidence; (3.) 
A probably fixed latent period of residence in the connective tissue — a period 
of incubation — of not less than twelve months (Lorimer, Mitchell) ; or of 
twelve to eighteen months (Busk). 

The Guinea-worm never makes itself manifest in the human body before 
the second season of residence in the places where it is endemic, a complete 
season being requisite to mature the worm. 

There are some remarkable cases which fix the period of incubation of the 
Guinea-worm in a very decided way. For example, in some excellent remarks 
on this subject by J. Mitchell, Esq., in the supplement to the Madras Times, 
of December 18, 1861, and January 13, 1862, it is related of a gentleman, 
well known to be extensively acquainted with natural history, that when he 

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170 TOPICS RELATIVE TO PATHOLOGY. 

■was travelling in the Northern Circars, the tents were pitched near a tank, of 
bad repute. He was accompanied by five friends, who, against his advice, 
bathed m the tank. Each of these five persons subsequently became affected 
with the (3ruinea-worm. In the Indian annals many accurate accounts are 
given which fix the period of incubation at about twelve months. 

Geological Features oj Locality and Soil' where the Bramncuiusis Endemic. — 
Evidence of a circumstantial kind tends to connect the parasite with some- 
thing geologically characteristic in the soil, mud, moisture,^ or water of the 
places where the parasite is endemic; yet information is still very imperfect 
on these points. Morehead believes that all the districts where Dracunoulus 
prevails are composed of the secondary trap rock — i. e., of igneous forma- 
tion, as in the villages of the Deccan and Northern Concan, where the para- 
site is indigenous. In the country between the Western Ghauts and the sea- 
coast, where the parasite is rare, the soil is a conglomerate ironshot clay, of a 
red color. 

Chisholm's investigations on this point led him to the conclusion_ that the 
districts where Guinea-worms abound (i. e., in man) are of volcanifi origin, 
with an argillaceous soil, holding much moisture, impregnated with salts or 
percolated by sea-water. Dr. Carter's evidence as to soil is, that the para- 
site abounds where the soil is a decomposing trap, of a clayey consistence, and 
of a yellow color. 

Every regiment which has occupied the lines at Secunderabad, "near the 
large tank called the ' Hansen Saughur,' " has suffered from the Dracunmlus 
(Lorimbe). The cause of the disease exists in or near the lines at that place ; 
and the soil is marshy which borders on the tank. The experience of the 19th, 
the 4th, 5th, 1st, and 35th Eegiments of Native Infantry all fix the locality 
of the Guinea-worm germs to be "in or near these lines." For example, the 
19th Regiment arrived at Vepery on the 20th May, 1838. It had been 
free from Dracunculus for five years before : twelve months after its arrival 
twenty-eight cases of Guinea-worm appeared, and several cases amongst the 
followers and children. The 45th Regiment occupied the same lines previous 
to the arrival of the 19th Regiment; and the disease appeared amongst them 
at the same season of the year and after twelve months' residence. The 
Guinea-worm had not been amongst them for many years before. At Peram- 
pore (in the 1st Regiment, N. I.) it manifested itself, after twelve months' 
residence, in March, April, and May. For many years previously Guinea- 
worm had been unknown in the regiment. Those who suffer most in canton- 
ments are those who use water of the filthiest kinds. 

On the authority of Scott, Smyttan, Chisholm, and Duncan, Guinea-worms 
are said to have been found in the earth or soil, and that they have been dug 
out of moist earth. There can be little doubt, however, but that the worms so 
found were specimens of the Gordiacece. 

In some form or another the Guinea-worm has an existence in moist earth 
and mud ; and it is probable that the hair-like worms found by gardeners in 
India coiled up together may be the young filaria of the Guinea-worm in 
sexual congress; whose progeny, as Zoosperms, or as filiform female worms in 
process of parthenogenesis (like the Tank-worm of Carter), make their way 
into the body. It is known that the Gordius aquaticus, when young, enters 
the bodies of large water-beetles, and at a certain stage of life it leaves its 
abode in the beetle and goes into the water, where it becomes a variety of 
Tanh-Yiona. It appears that there are white and brown Tank-worms — nay, 
that there are no fewer than seventeen species of minute Filaria (Caeter, 
Mitchell) ; and some say that all Tank-wonns are white at first, but become 
black after a time in the water (Gunthee). Observations are greatly wanted 
on these points. According to observations collected by Pallas and quoted 
by Vogel, it appears that even in Europe thread-worms like the G. aquaticus. 



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SPONTANEOUS EXPULSION OF THE GHINEA-WOEM. 171 

common in stagnant water and moist earth, can in certain cases infest the 
human subject CDe Infestis Viventibus intra Viventia, p. 11). 

The most obscure and incomprehensible parts of the history of this parasite 
are — (1.) The phase of its existence and that of its young after it leaves the 
body of man; and, (2.) The future life of the young, and their sexual differ- 
entiation. 

The parasite may be removed in several ways by surgical interference — 
either by cutting down upon it, or, after it begins to show itself, to commence 
winding it on a stick, gently pulling a portion of it out every day. But there 
is a natural termination to all diseases ; and it is a fair subject of inquiry as 
to what becomes of the Dracunoulus if left to itself, and its expulsion unaided 
by art. How would it be expelled, and what becomes of the progeny ? Is it 
probable that they would ever be placed in circumstances where they could 
lead an independent existence, becoming sexual and multiplying their kind ? 

In reply to these questions it is to be observed that there are undoubted ex- 
amples of the spontaneous evolution or expukion of the Guinea-worm. Scott 
once observed about five inches of the worm to start suddenly out, firm, 
elastic, and spirally twisted like a cork-screw, showing evidence of resistance 
to a progressive force from behind. So firm was the parasite that it supported 
itself for a little time perpendicularly to the limb. It is only when the animal 
dies that great mischief happens to the part where the parasite is. Then and 
there it acts as a foreign body ; but alive it does not cause disturbance (John 
Hunter, On the Blood, 4to, 1794, p. 208). The part first protruded is the 
head ; and its future progress, though slow and invisible, becomes in time very 
obvious (Scott). 

As an example of its spontaneous evolution or expulsion, Dr. Forbes relates 
that on one occasion eight Sepoys were admitted with Guinea-worm, and all 
of them had a characteristic vesicle on the ankle. These vesicles were opened 
on the fourth or fifth day. The loose skin was cut away with scissors, and a 
stream of cold water was poured daily on the part. Under these circum- 
stances the young were daily ejected from the proligerous tube of the parent 
parasite, and continued to be so for fifteen to twenty days. After this time a 
watery fluid only was emitted, without any young, but sometimes containing 
particles of a white flaky appearance, which continued two or three days 
longer. The Guinea-worm then became flaccid, and was discharged spon- 
taneously, without pain or swelling. The only exception was in one case, 
where the worm was constricted by the pressure of a band of areolar tissue, 
which led to retention of the young, and sloughing. 

Dr. Kennedy relates an anecdote which has an interesting bearing upon 
the spontaneous evolution and the probable future of the Guinea-worm after 
expulsion. "In 1791, when marching up the Ghauts with a Sepoy battalion, 
an African stepped out of the ranks and requested permission to go to a rapid 
running stream of water near by, in order to relieve himself, after his own 
fashion, of a worm in his ankle. The man unbound a bandage from his foot, 
loosened the worm (of which a part was extracted) from the cloth round 
which it was secured, and plunged his naked foot into the current of the 
stream. The constant but gentle force of the running water was sufficient to- 
stimulate the worm to come forth, and it was extracted almost immediately."" 
Another custom, recorded by Dr. Lorimer, illustrates the spontaneous evolu- 
tion, and points, at the same time, to the probable future of the Guinea-worm.. 
He says, "Many people belonging to the bazaars in the vicinity of the lines,, 
affected with the parasite, came for the express purpose of extracting the worm 
to the same tank where the men of the regiment bathe. The people so infested 
swim about in the water with the worm hanging loose, drawing the limb 
quickly backwards and forwards through the water, and from side to side, 
till expulsion is effected." The natives do not believe that they get the para- 
site from bathing in the water. 

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172 TOPICS RELATIVE TO PATHOLOGY. 

In these and similar cases the parent, being carried away in the stream, 
finds a place to die, and so gives freedom to her immense brood of young. 
The water seems congenial to the parent Guinea-worm, and sooner than any- 
thing else induces her to leave her position in the human body, and so to 
extricate herself, perhaps by stimulation of the muscular structures. This 
water method of extraction was also recommended by Dr. Helenus Scott, of 
Madras (Edin. Med. and Surg. Journal, vol. xviii). 

Vitality of the Parasite in Water. — It has been stated that young Dracunculi 
die in four, five, or six days, if placed in pure water from well or tank (and 
that is the case with many animals), simply for want of food. Water not 
pure is, no doubt, the proper element for them (Mitchell). Those artificially 
kept in impalpable red clay, partially covered with water, and exposed to the 
sun, were found alive after fifteen, eighteen, and twenty-one days, burrowing 
into the fine soft and ochry mud. 

Forbes experimented on two pups five or six months old. He poured down 
their throats water containing the young Guinea-worm Filarim. After three 
minutes the first pup became uneasy, sick, and vomited; the watery part of 
which was found to contain the animal still alive. Four hours after this the pup 
was killed, when abundance of Filaria were seen in the mucus of the stomach 
and duodenum ; but none showed signs of life. The other pup was killed 
twenty-four hours afterwards, but none were alive, although abundant in the 
mucus. Lorimer tried upon himself and others if the parasite could be prop- . 
agated by inoculation of the young Filarice emitted from the parent's orifice. 
Five besides himself were inoculated. He naively remarks that he is sorry to 
say they did not hatch in any, although in his own case he put them in their 
favorite place — ^namely, the foot and ankle. Such experiments were not likely 
to succeed, from the delicate nature of the young Filarim, and because they 
were introduced under unnatural circumstance-s. Inflammation and pus are 
inimical to the life of the worm. Besides, it is most probable that they enter 
the body in some other form. They seem to go through another stage of 
existence, and become sexual ; for it is only females, and these impregnated 
ones, which are found in the body of man. 

The impregnated females only of the progeny of sexual Filariae would 
therefore seem to be the Dracuneulus of man. 

Dr. Ewart, in his able paper on the vital statistics of the Meywar Bheel 
corps, writes as follows : " I am inclined to believe that Guinea-worm is prop- 
agated by a female and impregnated Zoosperm, and not directly from either 
the young of the full-grown female Guinea-worm or from tank- worms" 
{Indian Annals, vol. vi, July, 1859). Its generation is another example of 
parthenogenesis. 

Examination of Water, Mud, and Tanks. — In the months of August and 
September, 1837, Dr. Forbes examined several of the tanks in the vicinity of 
Dharwar, and found the mud on their banks, and in half-dried beds, abun- 
dantly supplied with animalcules {Filarice), some of them very much resem- 
bling those produced by the Guinea-worm when infesting the human limb. 
Their vermicular motion in the water is exactly the same; their general 
appearance is the same; and they are active and equally numerous. The 
point of a penknife inserted into the mud will raise up abundance for exami- 
nation. They are most numerous where the water assumes a variegated ap- 
pearance, with a pellicle floating on its ochry surface; and the fine, soft, 
impalpable mud just above water-mark contains most, and the best time to 
find them is about three or four o'clock in the afternoon. Two kinds may 
generally be detected in the soft mud: one kind is seven or eight times the 
size of the Guinea-worm young Filarim, the other exactly resembles them. 
The larger one may be the more mature form of the progeny after becoming 
sexual. The smaller one may be the first generation born of that sexual 



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THE TANK-WORMS OF INDIA. 173 

progeny — whose females, being fecundated, enter the body of man in this 
young and minute condition. 

Dr. Carter had medical charge of a school containing nearly 400 children. 
" One morning a case of Guinea-worm in a child little more than four years 
old was reported to him. There having been only two cases of this disease in 
the school during the previous eight years, Dr. Carter, who had before noticed 
the resemblance of the aquatic Filaria of Bombay to the larva of the Guinea- 
worm, was led to make inquiries, when he learned that the child was the son 
of the sergeant of the Industrial School, situated about three miles off, and 
had been only a little more than three months in the school. Upon further 
inquiry, he found that the sergeant's wife had then a Guinea-worm in her 
ankle, and that twenty-one out of fifty boys had been afiected with Guinea- 
worm during the past year. Some boys had had as many as five extracted, ' 
and ten more were then suffering from the disease, all of whom had been in 
the school more than a year. None of those who had been less than twelve 
months in the school had been admitted to hospital on account of Guinea- 
worm. 

" The boys were living in an embanked inclosure that had been taken in 
from the shore, the fourth side of which was formed by a cliff of the mainland, 
on which resided the sergeant and his family. In this inclosure were two 
small tanks, ten feet square, sunk in decomposing trap, one being six feet, the 
other three feet deep : the first furnished drinking-water, in the latter the 
boys bathed. The sergeant also obtained his bathing-water from these tanks, 
but the drinking-water from a well at some distance. 

" These tanks contained Confervm ; and every small piece as large as a pea 
contained twenty or thirty of the tank-worms. At the Central Schools, where 
there had been no cases, or only two in eight years, the Conferva} of the tanks 
failed to yield worms after the closest scrutiny. Hence he argues, and with 
apparently good reason. No tank-worm — No Guinea-worm; but that persons 
who bathe in water in which the former is found may expect to have the 
latter. 

" Dr. Carter further states that the Industrial School is situated near an 
old artillery barrack, now in ruins and overgrown with weeds, which had to 
be abandoned in consequence of the havoc made among all ranks, ofiicers as 
well as men, by this fearful parasite" (Mitchell, 1. c). 

The habit of the tank-worm is to bury itself under any organic debris that 
may be in the water in which it is found ; and if it be disturbed, it will imme- 
diately seek a hiding-place, nor rest until again covered. This implies that 
its proper habitat is the bottom of tanks, wells, or other reservoirs, among the 
decayed and decaying organic matter. It may be assumed that the water- 
carriers referred to by Dr. Morehead were Army Bheesties, who as such 
probably had access to good puckah wells (Dr. Morehead having found that 
Guinea-worm was not more common among them than among other people), 
and as the tank-worm, habitually resident in the mud at the bottom, would 
only be disturbed when the water became very low, and would get back again 
to its retreat, if possible, the fact of water-carriers being as little affected with 
Guinea-worm in the upper part of the body as other people does not carry so 
much weight as at first it would seem to do, and as it would in reality if the 
tank-worm was in the habit of swimming at the surface like many other 
aquatic animals. It has not been said that the worm finds its way into the 
body by any of the natural cavities of the body, such as the alimentary canal. 
On the contrary, it is supposed that the water may be drunk with impunity, 
as known by experience, and from the experiments of Forbes already notice* 

The young Filaria can work its way into a proper receptacle by its pointed 
extremity, " which is a long cone, ending in a point so inconceivably fine that 
the point of a cambric needle is a large marlinspike in comparison with it." 
But notwithstanding its exceeding tenuity, it appears tolerably rigid ; and as 

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174 TOPICS RELATIVE TO PATHOLOGY. 

the proper receptacle referred to is one of the sudoriparous ducts, a ready-made 
aperture exists for a distance quite long enough to contain so small a creature ; 
and it is by no means inconceivable to one who has seen its active exertions, 
that it should be able thus to hide itself in a foot or leg kept for some time in 
the water. It is unnecessary perhaps, to do more than allude to the well-known 
native custom of going into a tank to take water. In these tanks water-car- 
riers may often be seen standing for five or ten minutes at a stretch, chatting 
and washing themselves. They of course stir up the bottom mud, and if the 
tank-worm be there, and is the origin of the Guinea-worm, they certainly 
aiford it every opportunity to effect a lodgment. , One circumstance which 
makes this the probable mode of entry is, that natives et.re much more subject 
to attack than Europeans. 

Thus the evidence is very strong which refers the entrance of the parasite 
to bathing, walking, or lying on moist places where the tank-worms abound. 

Greenhow states that the sepoys of the Maiwara Battalion bathe in and 
drink the water of a well sunk in the limestone rock, which generally contains 
about twenty-eight feet of water, clear and sweet ; while the prisoners of the 
jail at Beaur use similar water from another well ; but they never bathe, which 
the sepoys do every day. The result is, that Dracunculus is much more preva- 
lent among the sepoys, compared with the prisoners, in the proportion of three 
to two. Again, amongst " Puchallies " the numbers affected are four times as 
great as among the men of the regiments. The former frequent the tanks 
more than the men of the regiments. 

Generation and Propagation of the Guineorworm. — The following periods 
'may be recognized in its natural history : 

(1.) , It is probably got by bathing in tanks or places where the young and 
impregnated females abound. 

(2.) A period of maturation in the human body takes place. 

(3.) A time favorable for extraction coines, when the animal seems to seek 
delivery from its imprisonment, to fulfil a new law of its existence. The 
adult animals perish annually. It is necessary they should die, that the 
young may live ; and, indeed, the Guinea-worm of the human body is not 
adapted to live. It has no functional arrangements for life. 

Men being exposed to the cause about the same time, the period for extrac- 
tion will arrive about the same time in all, but with just sufficient variation 
(as to time)_as to suggest the idea of contagion (Scott, Med. and Surg. Jour- 
nal, vol. xvii, p. 99). But the idea of contagion or infection from one man to 
another (as Bruce, McGrigor, and Paton wished to establish) is quite untena- 
ble. The evidence is all the other way. In Paton's cases onboard Her Maj- 
esty's ship "Cirencester," from 30th May, 1805, to 9th August of the same 
year, the origin of the disease is quite traceable to the preceding July and 
August, when the ship lay in Bombay harbor {Med. a7id Surg. Journal, 1806, 
vol. ii, p. 151). Sir J. McGrigor's cases in the 88th Regiment, and the 
absence of Guinea-worm among tlie a.rtillery on shipboard, related in his 
medical sketches, were not fully investigated. "We have no account of the 
water supply previous to embarkation. Afterwards he wrote a paper, or rather 
an account of the sickness in the regiment from all diseases, in the Edin. Med. 
Journal, vol. i, p. 270, and from this it appears that the regiment had been 
quartered in the Fort of Bombay, which is 'partly surrounded by a wet ditch; 
and several months after leaving this place most of the eases of Guinea- worm 
occurred. Bombay is well known to be extremely infested with Guinea- 
worm. 

Mosely is reported to have said that " there is as much foundation for believ- 
ing Dracunculus to be contagious as that a thorn in the foot is contagious." 
As observed by Rudolphi, the parasite is known to occur in persons who have 
neither eaten nor drank in the countries where it is endemic, but who have 
exposed themselves to its moisture and its mud. The moisture contained in 

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CONTAGION OP GUINEA-WORM IMPROBABLE. 175 

native canoes is sufficient to have carried to a ship oiF the coast the germs of 
the Guinea- worm, which find their way into the seamen of the ship, who are in 
the habit of going into these canoes with bare feet. 

JS"egative evidence, which would attempt to show that tank-worm does not 
exist, cannot be received. Most of the examinations on whicli such negative 
evidence rests have been imperfect; having been made with instruments 
confessedly imperfect, and perhaps by men not accustomed to use the instru- 
ment. I speak only of written and published statements, and on the authority 
of Dr. Lorimer. 

Problems for Solution. — Forty years ago Dr. Scott suggested that a patient 
and careful investigation of soils and waters ought to be made wherever Dra- 
cunculus is known to be endemic, and especially the soil round brackish wells 
and the beds of tanks. Morehead, in 1833, recommended that the following 
points be attended to, namely : (1.) Geological structure of the ground and 
nature of the site generally ; (2.) Nature of soil, wells, and well-water ; (3.) 
Nature of rocks through which wells are sunk ; (4.) Abundance or scarcity 
of water ; (5.) Seasons of increase or decrease of the disease; (6.) Opinions 
of natives. 

I desire very much to obtain specimens of Guinea-worm taken from the 
dead body long before the parasite arrives at maturity. 

The occurrence of Gninea-worm is sometimes defined by a distance of a few 
miles. So it is with many algse and minute water animals and plants as to 
habitat.* 

6. Filaria oculi. Length, /^jths to ."oths ; width, ^th of an inch. The 
body is, thick posteriorly, filiform, and ending in a pointed tail, transparent, 
and partly coiled up in a spiral form. The alimentary canal is surrounded by 
the folds of the oviduct. 

This Filaria (F. lentis) is very imperfectly known, and the female only has 
been seen. It was detected by Nordmann in the liquor Morgagni of the cap- 
sule of a crystalline lens of a man whose lens had been extracted for cataract 
by the Baron Von Grafe. In this instance the capsule of the lens had been 
extracted entire ; and upon a careful examination half an hour after extrac- 
tion, there were observed in the fluid two minute and delicate Filaria coiled 
up in the form of a ring. One of them presented a rupture in the middle of 
its body (probably made by the extracting needle), from which rupture the 
intestinal canal was protruding. The other was entire, and measured about 
yljths of an inch in length.. It presented a simple mouth, without any 
apparent papillae, such as are seen to characterize the large Filaria which 
infests the eye of the horse ; and through the transparent integument could 
be seen a straight intestinal canal, surrounded by convolutions of the oviducts, 
and terminating at an incurved anal extremity (Owen, p. 64). 

* My friend, H. C. Baotian, Esq., M.B., Professor of Pathology in University Col- 
lege, London, has recently furnished a most interesting account of the anatomy of the 
Guinea-worm to the Linnasan Society, and has been kind enough to furnish me with 
drawings of his observations. He writes to me as follows ; " Since I saw you last I have 
discovered several species of Carter's ' tank worms ' in soft mud, &c. (at J'almouth) ; 
that is, small Nemaioids, agreeing in almost every respect with those found by him in 
Bombay. The more I see of these, the more thoroughly am I convinced of the 
undoubted relationship existing between them and the Guinea-worm, coinciding as 
they do in their anatomy even to minute details, and in many respects where there is 
a salient distinction between the anatomy of the Dracunculus and that of the Aacari- 
des. One which I sketched to-day had an exsertile rigid, sharp-pointed oesophagus. 

" The great difficulty in the theory is to account for the fact of the localization of 
the disease, whilst these animals are probably so widely spread ; and I suppose it is one 
particular species which is limited in its diffusion ; but I suspect that many of those 
others will hereafter be discovered as parasites in animals or vegetables. The Vibrio 
tritico I have examined, and find it to be a worm essentially similar ; and Dr. Cobbold 
tells me that he has found a long thread-like worm in the subcutaneous tissue of the 
back of a water-bird. The whole question wants working out." 

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176 TOPICS RELATIVE TO PATHOLOGY. 

A Filaria oculi vel lachrymalia has been described as not uncommon among 
the negroes on the Angola coast, where it is called loa; also at Guadaloupe, 
Cayenne, and Martinique. Its length is l/^ths to.ly'pths of a line. It is a 
filiform, slender worm, pointed at one end, obtuse at the other, tolerably firm, 
and of a white-yellow color. 

This parasite has been considered a Strongylus by some, by others a young 
Guinea-worm, and by others as an Oxyuris vermicularis. 

7. The Strongylus bronehialis was first discovered by Treutler, in 1791, 
infesting the enlarged bronchial glands of an emaciated man. The parasite 
is cylindrical, slightly narrowed anteriorly, filiform, but somewhat compressed 
at the sides, semitransparent posteriorly, and of a blackish-brown color. It 
measures from, half an inch to three-quarters of an inch in length. 

8. The Eustrongylus gigas is fortunately rare in man, though common in 
a great variety of animals, such as weasels. It inhabits the kidney, destroy- 
ing the substance of the organ, the walls of which become the seat of calcare- 
ous deposits. 1 

9. The Sclerostoma duodenale is known to be tolerably common throughout 
Northern Italy; and, according to Pruner, Bilhartz, and Griesinger, it is so 
remarkably abundant in Egypt, that about one-fourth of the people are con- 
stantly suffering from a severe anaemic chlorosis, occasioned solely by the 
presence of this parasite in the small intestines. 

" Its length is about one-third to half an inch, its width about one-twentieth 
of its length. Its head has a round apex, and its extremity, which is bevelled 
at the expense of its posterior surface, is provided with booklets that occupy 
converging papillse. The mouth contracts, to open into a thick muscular 
pharynx, which, widening as it passes downward, ends, after occupying one- 
seventh of the body, in the intestine. The sexual differences of the male and 
female are very interesting. Its pathological significance is chiefiy due to the 
hemorrhage caused by these parasites, which are often present in thousands 
between the valvidm connivenies of the duodenum, jejunum, and Ueum, and 
not infrequently in the submucous areolar tissue. In short, the physician 
practicing in Egypt must never forget that the chlorosis of this climate is often 
the result of repeated and small hemorrhages from the intestine, caused by 
these parasites. Turpentine, as Griesinger points out, promises to be the best 
remedy both as a styptic and as a vermifuge" (Brit, and For. Med.-Chir. 
Review, I.e.). 

10. The Oxyuris vermicularis was known to Hippocrates, and is one of the 
most troublesome parasites of children, and occasionally of adults. It is a 
minute, white, thread-like worm, the male being about a line and a half in 
length, and the female five or six lines. They inhabit chiefly the rectum, 
where they are often found in clusters, rolled up in balls of considerable size, 
and from the rectum may creep into the vagina or urethral orifice. Some- 
times they give rise to profuse and exhausting bloody discharges from the 
vagina. 

The eggs of this parasite have embryos developed within them prior to their 
escape from the parent; and in this respect they differ from the A. lumbricoides 
and the Trichocephalus on the one hand, and from the viviparous Draeunculm 
on the other. In this character, however, they resemble the A. mystax. 

In all probability the young escape from the eggs soon after the latter are 
expelled,, or migrate per rectum, and, like others of the Nematelmia, gain access 
to the human body with our vegetable food or water whilst still in a sexually 
immature condition. 

Treatment of those Infested by the Round Worms. 

The habitat of the Ascarides being fpr the most part a collection of mucus, 
tiie means used* for their expulsion are such as may expel mucus. Four grains 



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REMEDIES FOK EXPULSION OF ROUND WORMS. 177 

of compound scammony powder, ■with five grains of aromatic poivder ; or two to 
three grains of calomel and ten grains of jalap, taken at bedtime, are useful. 
In weakly children, small doses of Epsom salts will ultimately effect the same 
object, and with less distress to the patient. Many persons place great confi- 
dence in calomel as a medicine capable of destroying round worms ; but it does 
not appear to act beneficially except as a purgative, expelling the mucus. 
The day after the administration of the purgative, the patient ought to be 
kept on low diet, without solid food ; only a little beef tea being taken ; and 
on the second day — the day succeeding the purgative — from five to ten grains 
of the ethereal extract of santonin may be given during the day ; or from three 
to four grains of santonin itself.* 

About three doses are suflicient ; one every second night, followed by a 
brisk cathartic the morning after each dose. It may be compounded as troches, 
containing one or two grains in each ; or two to six grains may be dissolved 
in one ounce of castor oil, and a teaspoonful given every hour till the oil ope- 
rates. A santonate of soda is also recommended by Kuchenmeister in doses of 
two to four grains. Santonin seems to be a specific for the destruction otAscaris 
lumbricoides ; but it may be necessary to state to the patient or his friends, that 
the sight sometimes becomes perverted as to color, after a few doses, and color- 
less objects may be seen to be blue or yellow. 

The Oxyurides, or small vermicular Ascaris, being situated so near the rec- 
tum, enemata have at all times been much used in the treatment of these 
cases ; and injections of oil have been much commended, especially of castor 
oil, olive oil, or sweet oil. But these animals will live from thirty -six to forty- 
eight hours in castor oil. Indeed, very little benefit has been derived from 
any such local treatment. Warm water injections tranquillize the intestine, 
and give more temporaiy relief than anything else. The Oxyurides are killed 
by cold ; and injections of cold water, with a little vinegar, are very efiica- 
cious. If the child is a vigorous child, large injections of very cold water may 
be administered, with vinegar or a few drops of ether or of alcohol. In obsti- 
nate cases, a weak solution of corrosive sublimate, in the proportion of one 
quarter of a grain to two ounces of enema. Injections of the following bitter 
substances have been found very useful in the treatment of the Ascaris ver- 
micularis : Three or four ounces of a strong infusion of quassia repeated three 
or four times, or of steel and quassia and aloes, or a solution of common salt in 
gruel, or a similar quantity of lime-water, has been found of service. At the 
same time it is also well to administer internally some bitter medicines ; — for 
example, half an ounce (or any dose suitable to the age and strength of the 
child) of compound decodion of aloes, taken in the morning fasting, once or 
twice a week ; and three ounces (or other suitable dose) of infusion of quassia 
may be taken every morning that the aloes is not taken. 

Chloride of sodium, to the extent of an ounce in a pint of quassia infusion, 
has also been found a useful injection ; so also has an enema composed of 
aloes, carbonate of potash, and mvailage of starch. But whatever local reme- 
dies are used, it is necessary to attend to the general health, which usually is 
at fault, and to persevere in the use of enemata twice a week for several 
months. The digestion is generally slow and imperfect, the secretions from 
the mucous membrane of the alimentary canal being abnormal. For this 
condition, small doses of the extract of nux vomica, with sulphate of iron, in 
extract of gentian or aloes, or in rhubarb or colocynth pill mass, taken twice a 
day, will be found of great service. 
i .^ 

* Santonin is a crystalline neutral princi^ile obtained from the Artemisia Sanionica, 
or Semen Contra, — which is not a seed, but is the unexpanded flower-head of a species 
of Artemisia imported from Kussia, and is the only so-called worm-seed which yields 
Santonin in quantity worth extracting. It is a tasteless and pleasant vermifuge for 
children (Squire). 

VOL I. 12 

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178 TOPICS KELATIVE TO PATHOLOGY. 

From what has already been written, it will be seen how important it is, in 
the treatment of all these parasitic diseases, to take every means of utterly 
destroyittf/, by huridng or by chemical agents, all debris or excreta which may be 
passed by patients suffering from these parasites, and also how necessary it is to 
look lueil to the purity of all luater supply used either for the purposes of food, 
drinking, or bathing, and to the quality of pork or bacon, especially in connec- 
tion with the Trichina spiralis; the use of bad tiour in connection with the 
eggs or larvte of Ascaris or Oxyuris (Stein). 

CLASS B. STERELMINTIIA, OR SOLID WORMS. 

11. Bothrioceplialus latus. — Although classed with tape-worms, Bvthriu- 
cephali differ essentially from Tcenia. Two species have been found in man, 
namely, — (1.) Bofhriocephalus latus ; and (2.; Bothrioc£pjhahis cordatus. 

The Bothriocejjhalus latus is endemic chiefly in the north of Europe, .and is 
found more especially in Russia, Sweden, Norway, Lapland, Finland, Poland, 
and Switzerland. The inhabitants of the French provinces adjoining Switz- 
erland are infested with both species. 

Instances of Bothriocejjhalus latus are said to have occurred both in Eng- 
land and France; but, when carefully inquired into as to their history, it will 
be found that this parasite maintains a very fixed geographical distribution. 
For example, — of the six specimens in the College of Surgeons of England, 
one is from a native of Switzerland ; one from a Russian, belonging to the 
Russian embassy in London ; one from a person who had been travelling in 
Switzerland ; a fourth happened in the practice of Dr. Gull, in the person of a 
little girl from Woohvich, where there is always a number of foreign ships 
and sailors, bringing with them native food and water ; another was passed 
b}' a native of Russia, who, after a long residence in England, paid a tempo- 
rary visit to his birthplace, and returned to England with this parasite as a 
pleasant memento of his native country. 

The liability to this form of parasitic disease appears to be greatest towards 
the seacoasts and along river districts. Huss, of Sweden, describes it as 
extremely common on part of the Lapland frontiers, in Finland, and on the 
shores of the Gulf of Bothnia. On the extreme coast there is scarcely a 
family together free from it — old and young, rich and poor, native and emi- 
grants, alike suffer from this worm; and in one or two large towns on the 
mouths of rivers, at least two per cent, of the population experi- 
Fm. 20. gn(,g ;^g attacks. On passing inland the frequency of the disease 
diminishes, until, eight or ten leagues from the coast, rivers, or 
lakes, it almost ceases to be found. The natives believe it to be 
hereditary. Dr. Huss attributes it to the use of salmon {Brit, 
and For. Med. Review, 1. c. ). 

The head of the Bothriocephalus latus is peculiar, and very 
different from the T. solium. It is of an elongated form (Fig. 20), 
compressed, with an anterior obtuse prominence, into whicli the 
mcjuth opens ; an opaque tract extending from the mouth separates 
two lateral transparent parts, which are supposed to be depres- 
sions. There are no traces of joints till about three inches from 
the head ; and throughout the entire body the segments have more 
length than breadth. The whole length of the mature parasite 
varies from six to twenty feet. It is of a grayish-white or yellow 
color ; and the ova are very brown, giving the mature segments a 
very marked appearance. The neclc is not always obvious, for 
the worm has the power of making it long and thin or thick and short; and 
there are no joints or segments to be seen in it, but merely prominent ridges. 
The segments, when they become first apparent, are nearly square : but after- 
wards they become much wider than they are long. There are two orifices 

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BOTHRIOCEPHALUS CORDATUS. 



179 




Fig. 21. 



on one of the flat surfaces of each segment; the anterior orifice is connected 
with a male organ of generation, the posterior is connected with 
the female. The proglottides are never passed singly, but always ^"^^ -^"■ 
in chains of many links, and particularly in February, March, 
October, and S'ovember. The ova (Fig. 21) are always discover- 
able in the fmces, of an ovoid form, with a perfectly translucent 
operculated capsule, through which the segmented yolk is dis- 
tinctly visible; and at the period of discharge of the "proglottides 
the ova show merely the stage of segmentation of the yolk. The 
six-hoohed embryo, cased in a numtle studded with vibratory cilia, 
develops itself after segmentation, protected by the capsule in fresh 
water, for several months after the expulsion of the proglottides. 
When so far matured, the lid of the capsule opens up, and the cili- 
ated embryo escapes (Fig. 21rt.), and becomes globular in shape, 
and moves actively about for a considerable period (a week ). If 
during this period they do not succeed in obtaining access to the intestine of 
an animal adapted for their development, they lose ^^^ ,,, 

the ciliated mantle, and perish. When these em- 
bryos are introduced by experiment into the intes- 
tines of mammals, the scolices and mature Bothrio- 
cephalus were found. Experiments in which living 
embryos were introduced by implantation between 
the brain and dura mater, and into the eyes of dogs, 
also under the skin of frogs, and by injection into the 
bloodvessels of mammals, give a negative result; 
quoad the development into cystieerci or scoHces. So, 
also, feeding experiments with the scolices of the 
Bothriocephalm found in various-fish lead to negative 
results; just as the feeding of fish with the eggs 
themselves. It is therefore justifiable to assume that 
drinking-water from lakes and rivers is the medium 
through which the living embryos of the Bothrioceph- 
alm lahis find their way into the intestines of men 
and of mammals (Dr. J. Knoch, Petershurger Medi- 
einische Zeitschrift, 1861; Cobbold, 1. c). 

12. Bothriocephalus cordatus This species (Fig. 

22, a) is new to science, and has only very recently 
been described by Leuckart, who received about 
twenty specimens from Godhaven, in North Green- 
land, one of which was from the human intestine. 
The parasite measures about a foot in length, and 
exists in dogs in considerable abundance. It differs 
from Bothriocephalus latus in the form of the head, 
which is heart-shaped (Fig. 22, b and b'), or obcor- 
date, short, and broad, and set on to the Ijody with- 
out the intervention of a long neck. The segments 
are distinct from the very commencement, near the 
head ; and so rapidly do they increase in width, that 
the anterior end of the body becomes lancet-shaped. 
About fifty joints are immature ; and in the largest 
example Leuckart counted a total of 660 joints. It 
displays a greater number of the calcareous corpus- 
cles, and a greater number of lateral uterine pro- 
cesses (Leuckart ; Cobbold, " Remarks on the 
Human Entozoa," in Proceedinns of Zooloriicnl ("> Soihr,«,phahn cordaiy.^ 

ri • , -XT -tonk\ J •' J naliiral sizi^ ; (/j.) Head, back 

liOCiety, JNOV., lobZj. view, maninflwl Ave diameters; 

13. Taenia solium.-In their mature condition the Z^^::^^Sl^^^'"'^' 




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180 



TOPICS RELATIVE TO PATHOLOGY. 



tape-worms are all more or less jointed eutozoa, of a riband-like form, marked 
with bands, or girdled. Each mature joint or segment is of hermaphrodite 
conformation, containing at once male and female reproductive organs, which 
produce fecundated ova. In their immature condition the embryo jjenetrates 
the tissues, and becomes encysted. In this stage of development they are 
known as the " cystic eutozoa," because they terminate in a bag or cyst. 

Eight varieties of true tape-worms have been found in man, and the t^Y'o 
varieties of the BotJiriocephalus already noticed. 

But two only of the true tape-worms are of frequent occurrence — namely, 
the T. solium and the T. mediocanelkda. The former is the one endemic in 
this country ; the latter is the more common tape-worm on the Continent, in 
South Africa, and India. 

These tape-worms have been known for a very long period ; but they have 
not always been distinguished from each other. Indeed, the distinguishing 
characters are but recently known. They have often been confounded together 
imder the name of "solitary worm," because it was believed they lived singly. 
This, however, is a mistake. 

The 1\ solium and T. mediocanelkda appear at first sight to be very similar 

to each other in general appearance. The latter is much the larger of the two. 

It is only in the alimentary canal — the small intestines of man and other 

animals — that Tamice become sexually mature, in natives and native animals 

of all countries. The Tien.ia is very common 
^"'- 23- in natives of Abyssinia ; — so common is it 

there, that its absence is the exception to the 
rule. The affection is there looked upon as 
a natural occurrence ; and so general is this 
belief, that when a slave is sold into Abyssinia 
he provides himself with a plentiful supply 
of kousoo — the local remecly for expelling 
the parasite. 

The Tcenia solium is a common tape-worm 
of this country. It is composed of segments 
of variable size, numbering from 800 to 1000 ; 
and these being endowed with considerable 
contractile power, the length of tape-worms 
varies greatly, and so also does the width 
and thickness. Nine to thirty-five feet may 
be quoted as average measurements of length. 
The body narrows from the posterior to the 
anterior extremity, till towards the head it 
becomes a mere thread. The parenchyma 
is soft and white, with microscopic calcareous 
particles, sometimes mistaken for ova (because 
they are round or oval), scattered through 
nearly every part. 

The Head (Fig. 23) is very small, but it 
may be seen with the naked eye to be of a 
globate or triangular form, with black pig- 
ment ingrained into its substance, which may 
be the remains of blood. On the most ante- 
rior part of the head, with the aid of a lens 
magnifying twenty-three or twenty-five di- 
ameters, four circular projections, equidistant 
from each other, may be seen. Each has a 
circular disc or cup, surrounded by a rim of 
dense tissue. The parasite is able to elongate 
so that, while opposite ones are put forward, 




Head and neck of Tainia solium. 
(a.) Circle of hooks. 



and retract these projections ; 



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ANATOMY OF TAPE-WORM SEGMENTS. 



181 



Fig. 24. 



the two others are kept back. Between the suckers, aud anterior to them, is 
a couvex protuberance or rudimentary proboscis, which is impervious, and 
surrounded by a double row of liooks (Fig. 22, a, also Fig. 23). These are 
siliceous, and number twelve to fifteen in each row. The shape of these i.s 
peculiar. They consist of a straight stem or handle, a middle nob, aud a dis- 
tinct hook or claw, surrounded by a sheath or sac. Bremser believes that a 
tcEnia loses these as it gets old ; or it may shed them periodically by rows ; 
and being lost, they may not be renewed, and so the parasite may be got rid 
of in the course of nature. 

The head terminates a long and slender neck, on which there are trans- 
verse markings, but no visible joints or articulations. Such joints distinguish 
the body ; and these joints, segments, or zoonites are united end t(j end in a 
single linear series. 

The characters of the segments vary at different parts of the l)ody. They 
are square or oblong ; and in the mature part of the animal the length of them 
is equal to twice the width. The anterior border of each segment unites with the 
anterior or previous segment, aud is thinner than the posterior border, aud also 
narrower. The posterior border is thick, and projects or overlaps the border 
of the. segment next in order, and is undulating or indented. The lateral 
margins incline to each other anteriorly. The two surfaces are flat or slightly 
elevated towards the centre. 

Each mature segment contains male and female organs of generation. The 
opening at the side of each segment is the 
sexual aperture, indicated by a prominent 
fiapilla. These openings are sometimes at 
one edge, and sometimes at the opposite 
edge. Two, three, or four consecutive seg- 
ments may have them on the same edges, or 
on opposite ; but there is no regular alterna- 
tion. With a lens a cup-shajjed depression 
may be seen, sho\\'ing two mesial apertures. 
From one of these a lemniscus or rudimen- 
tal penis projects, connected with a horizon- 
tal (deferent) canal (sometimes indicated 
by a dark pigmentary material ) from a vesic- 
ular body in the middle of the posterior 
end of the segment (Owex). 

Behind this male orifice is the opening to 
the female organs, by a canal leading to a 
lobulated organ, wdiich is the ovary or germ- 
stock. These parts are more distinctly developed the farther the segments 
examined are from the head end of the worm. While the head continues to 
adhere, by its circles of booklets and oscula, to the mucous merabraue of the 
intestine, the last or caudal joints, when they have arrived at sexual maturity, 
are separated one by one, or in numbers together, and new joints are at the 
same time gradually formed behind the head. The total number of joints in 
a twnia, ten feet long, has been counted, and found to number upwards of 
800 ; and the joints ajjpear to be sexually mature about the four hundred and 
fiftieth segment from the head. Thus growth and development take place 
mainly towards the neck of the parasite, by a process of transverse fission ; and 
thus a segmented individual or compound animal appears to grow. This seg- 
mentation of individual links by transverse fi.ssion ceases when the organs of 
generation begin to develop themselves in them ; and when those are com- 
plete, the segment or link has arrived at sexual maturity or completeness. It 
is now called a ■proglottis. Thus all the new segments come to be developed 
between the head and those which are advancing to sexual completeness ; and 
if the characters of complete sexual development be taken as the distinctive 




Circle of hooks more lii^^lily magnified 
(after Licuckakt). 



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182 



TOPICS RELATIA'B TO PATHOLOGY. 




mark of individuality, then each segment of the tape-worm may be looked 
upon as a distinct animal ; and this separation by iission or segmentation may 
be considered as analogous to what takes place in the medusaj or polypes— a 

kind of alternate generation, in which, 
Fig. 25. the segments, zoonites, or 217-ogloUides 

may be regarded as making up a col- 
ony of animals. It is only in the ali- 
mentary canal of man and other ani- 
mals that the tape-worms, or cestoid 
entozoa, attain to sexual maturity; 
and in all of them the ova are fecunda- 
ted before being discharged, and may 
often in the T. solium be perceived to 
have undergone the first stage of their 
development before they are excluded 
from the oviduct of the mature seg- 
ment. The expulsion of the ova oc- 
curs in some one of the following ways : 
( 1.) The impregnated segments sep- 
arate from each other, and passing out 
of the body singly or in numbers with 
the faces or without any fecal evacua- 
tion, become decomposed, and so the 
eggs are set at liberty. The activity of 
these separate segments is retained for 
a considerable time after passing out 
of the body — a circumstance which led 
to their being at one time taken for a 
distinct species of worm, to which the 
name of Vermes cucurhitini (from re- 
semblance to a pumpkin-seed) was ap- 
plied. The contracted ajipearances of a 
segment during its movements out of 
the body are represented by the forms 
shown in the accompanying woodcut 
(Fig. 26> 

One may feadily observe the activ- 
ity displayed by these beauties of na- 
ture as they disport themselves on the 
recently extruded excrement of almost 
every constipated dog. The expelled 
joints may be seen to become violently 
contracted shortly after their expul- 
sion, as if the stimulus of physical cli- 
mate in their new situation provoked 
excessive contortions. The long single 
joints thus expelled become still more elongated by contractions of their trans- 
verse fibres, while the alternate contractions of these fibres with the longitu- 
dinal ones cause shortening of the joint to such an extent that its breadth ex- 
ceeds its length. Such a sequence of contractions produces movements which 
simulate those of progression in a worm, and thus these segments may be seen 
to move some little distance from the spot on which they may have first fallen, 
discharging ova during their march from the interior of the segment. Thus 
they may move about for a time; but the growth of the myriads of embryos 
in the interior of the proglottis causes it sooner or later to burst, when the • 
embryos become scattered over grass or ground, dispersed in drains, sewers, 
ditches, surface water, or waste places, while wind and insects help to diffuse 
them still farther. 



Proglottis of TccTtia solium magnified. — (a.) Geni- 
tal pore, witli its preputial cover or slieath-skin ; 
(?).} Lemniscus or penis; (c.) The oviduct; {d.) 
The seed-vessel ; fe.) The uterus; (/.) The water 
vascular system of vessels (after Rokitansky). 




Proglottides of a Tamia (medwcavellata) in va- 
rious stages of contraction (after Leuckart). 



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STRDCTUBE OF TAPE-WOKM OVA. 



183 




12) 






(2.) Eggs are thus discharged through the genital pores of tlie mature seg- 
ments; and if the segment be sliglitly squeezed, the ova may be pressed out. 

(3.) The mature joints of the adult tape-worm seem, in some instances, to 
vuidergo a disintegration within the intestine of the animal they live in. 
Thus, Kuchenmeister on one occasion found the wall of the large intestine of 
a dog occupied by a white sandy powder, the particles 
of which, on examination under the microscope, turned 
out to be innumerable ova of a T. serrata which lived 
higher up the bowel, accompanied by its separated 
joints. 

Such contingencies, as in (2) and (.3), are not un- 
likely to happen within the rectum, when, by constijia- 
tion or otherwise, the matured joints are retained, and 
constitute one of the most serious dangers which the 
matured tape-worm inflicts on the animal it inhabits, 
and one of the strongest indications for its removal. 
It has been recently ascertained that in one or two in- 
stances the presence of a Cydicercm tehv celhihscv (the 
embryo of the T. solium ) has been found to coexist with 
the previous prolonged existence of a T. solium in the 
intestinal canal of the human subject. 

The mature segments are often expelled from the 
human rectum at the rate of six or eight a day, some- 
times with the excreta, and sometimes ^;fr se; and they 
exhibit evidence of very active vitality for some time. 
Moisture is favorable for maintaining their existence, 
and for favoring the spread of the eggs over herbs, 
grass, ground, fruit, or vegetables, wdiicli may become 
the food of man or of cattle. 

The structure of these ova (Fig. 27) is peculiar; and 
the provisions possessed by their coverings for preserv- 
ing the embryo are important points for consideration 
in connection with their transmissions through ap- 
parently impossible conditions into the bodies of ani- 
mals,' where they become further developed; and in 
conuection with their powers of resistance to therapeutic 
agents (which have been called anthelmintics or vermi- 
fuges) administered for their removal. 

It is only in their earlier stages of development that 
they are really the analogues of ordinary ova. In the 
blind extremities of the oviducts of the mature joint of 
the tape-worm the shells of the ova appear to be com- 
posed of a calcareous transparent substance; antl by 
the time the ova reach the central segments of the tube 
their hitherto transparent calcareous shell becomes not 
only much thickened, but is converted into a dark- 
yellow or brown mass, in the interior of which the em- 
bryo is formed. The egg at first is of the simplest 
structure, and very minute, Ix'ing only about v-g^th 
, part of an inch in size. The admixtvire^ of these or- 
ganic elements with the calcareous shell imparts to it 
that extraordinary power of resistance to chemical, and 
even mechanical, violence which it certainly possesses. 
Dilute acids and alkalies have little immediate effect 
<on this leathery husk ; and even after hours of immer- 
sion in them, scarcely more than a slight swelling and transparency is pro- 
duced upon the shell. It is, therefore, no matter of surprise that after 

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Developmeut of the ovum 
of Ttcnia solium. — (1,) Previ- 
ous to segmentation ; (2, :i, 4, 
5) Segmentation in tlie im- 
pregnated ovum; (0.) Ap- 
pearance of tlic early em- 
bryo, witli its tliree pairs of 
siliceous .spikelets; (7.) Jla- 
ture condition of tlie ovum 
containing the embryo in- 
closed within its leathery 
case (after Leuckakt). 



184 TOPICS RELATIVE TO PATH0L08Y. 

months of exposure to warmth and moisture, or to cold and dry air, the 
pulpy, putrid, or dried-up mature segments of tape-worms should yield ova 
which show no sign of degeneration or decay. 

A more or less speedy death of the expelled segments is followed by their 
putrefaction, hastened, it may be, by warmth and moistura The eggs in their 
interior are then set free, to be carried by winds, waters, or other agents, 
■wherever accident may determine. Thus they may lie to rot upon the soil, or 
they may be consumed as food by various animals which feed on such minute 
particles of food. The minority of the^e eggs, after many and long wander- 
ings of this passive nature, may at length be engulfed unconsciously by some 
unfortunate animal with its food. 

Within the alimentary canal of the animal which is thus so unfortunate 
as to eat the egg, a small embryo of most simple form is set free from the 
ovum by the rupture of the calcareous husk which incloses it. Such rupture 
is absolutely necessary to liberate the embryo, and may be effected by 
mechanical violence, such as friction, or crushing by the teeth in mastication 
of the food, rather than by solution or digestion in the stomach. Animal 
heat does not seem to be alone suiRcient, nor is mere moisture sufficient, to 
liberate the embryo; which when set free consists of little more than a 
highly contractile vesicle about the same size as the yolk of the ovum, measur- 
ing only about the j^Voth of an inch. It is peculiarly armed for progression 
by boring its way through the most delicate tissues. On one side of it are 
placed three pairs of spikelets ; one pair points forwards, and the two other 
pairs are so placed that a pair is towards opposite sides of the embryo, or at 
right angles to the anterior pair. These spikelets are shown in the last two 
drawings of Fig. 27. 

The embryo when free is named a " proseolex," and commences life on its 
own account by eflforts at active migration. By the vigorous exercise of the 
spikelets it makes a passage through membranes, walls of vessels, and textures 
of solid viscera, so as to reach localities where it becomes ency§ted, and passes 
another phase of existence. The first portion of its path is pierced by bring- 
ing close together the several pairs of spikelets so as to form a kind of wedge- 
shaped stiletto. The lateral pairs of these spikelets are then brought back- 
wards to a rectangular position, and so they thrust the embryo forwards in 
the direction in which the anterior pair of spikelets pointed. Similarly 
repeated actions eventually accomplish progression to a resting-place ; and 
the action may be aptlj^ compared to the movements of the arms and attitude 
of the head of a swimmer. But this active migration is not the sole means 
by which the embryo Tcenia is enabled to traverse the animal body. The 
embryo may penetrate a mesenteric vein, when it will at once be swept onwards 
by the current of the blood to the portal vein, and passing into the minute 
ramifications of the portal system, may find a resting-place in the liver. 
Leuckart has found the embryos of tape-worms in the blood in such large 
numbers that he inclines to regard the currents of the blood in the vessels as 
the ordinaiy and more usual channels for the migration of the embryos. It 
also explains the wide diffusion of tape-worm embryos as cysUcerei or echinococd 
in various stages of development throughout viscera of the body, where they 
become encysted, and especially their very frequent site in the liver, perito- 
neum, and mesentery. Thus far completed and encystic, the embryo is called 
a " scokx," and as such in Oysticercus telce celluloses was fii-st described by 
Eainey. The embiyos of Echiiioeocci and Ccenuri give rise to numerous scolices, 
which complete their development into tape-worms in the alimentary canal 
of another animal, when that animal happens to eat the liver or brain con- 
taining the cysts of such Echinococd or Ccenuri ; but the embryos of such 
echinococd or ccenuri tape- worms find their way into man or animals wth 
drinking-water, or with raw, uncooked articles of vegetable diet from moist 



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TfiNIA MBDIOCANELLATA. 185 

soils, such as salads, roots, fallen fruit, all of which may be doubtless so ex- 
posed as to receive the germs or ova containing the embryos, passed along 
with fecal excrement of dogs especially, and which, after being dried, are 
carried by wind or water in all directions. 

The third stage of development consists in the formation of segments, which 
are jfii-st seen in the form of marks, like girdles, surrounding that portion of 
the entozoon next to its oscula and booklets, and which terminate in a caudal 
vesicle. _ It is now an incomplete segmented Tania, and in scientific nomen- 
clature is called a Strobila; and the development to this stage may occur 
while the entozoon is still within the closed cyst which has formed round it. 
It is only in the alimentary canal of animals that the last and perfect stage 
of development is attained, by the tape-worm reaching sexual maturity. The 
segments or links marked off by the bands, joints, or girdles, in the encysted 
Strobila embryo become mature segments by the development of sexual organs 
within them. This only takes place after the Strobila embryo has passed into 
the alimentary canal of an animal which can afford it a place to live and 
spend the rest of its days as a fixture attached by its hooks to the mucous 
membrane. The human alimentary canal is an oft-chosen place of the 1\ 
solium and T: medioeanellata. Here the tape-worm forms ■ complete sexual 
segments or links, each being hermaphrodite, and tending to separate when 
completely mature. 

After living for some time in this prolific condition, and having produced 
often a -very large nvimber of joints and an enormous quantity of ova, the 
existence of this troublesome parasite is terminated by the separation of the 
animal from its attachment to the intestinal membrane. When this separa- 
tion occurs spontaneously, it may be that the circlet of booklets being shed peri- 
odically, or being lost, they are not renewed, and so the prolonged life and 
romantic vicissitudes of a tape-worm may be thus brought to a natural termi- 
nation. The whole length of the beast is then ignominiously expelled, while 
some reputed vermifuge, however innocent, may get the credit of its death. 
The apparent success of many such parasiticides is recorded and measured by 
yards of tape-worms, which, being ingeniously bottled by worm-doctors and 
charlatans, are duly advertised to have been passed by John Smith or Sarah 
Brown, after they had been dosed with the "infallible" remedy. 

The length of the tape-worm in the human body has been known to exceed 
thirty feet, and there are grounds for believing that the T. solium may attain 
to this size in the human intestine in about three or four months. 

15. Taenia medioeanellata. — This is a bookless, flat-headed tape-worm, the 
cysticerd and embryos of which are developed in the muscles and internal 
organs of cattle (Lexjckaet) ; and man becomes infested with tape-worm by 
eating imperfectly cooked veal and beef in which the cysticerd abound. It 
was first discovered by Kuchenmeister in 1855, and then shown by him to be 
different from the T. solium. Its head (Fig. 28), is large, obtuse, and trunca- 
ted, and carries no hooks. Its sucking discs are much larger than those of the 
T. solium, as if to compensate for the want of the hooks. Its segments, when 
mature, separate easily. The ovaries are simple, giving off sixty lateral par- 
allel branches. The eggs are similar to those already described. 

The T. medioeanellata has been found in several instances of invalid soldiers 
who died at Fort Pitt, and at the Royal Victoria Hospital at Netley. In one 
instance three very large and long worms existed in the small intestines, each 
of them precisely similar in all respects. The soldier in whose intestine they 
were found died of diabetes mellitus, and he had been a cook for many years 
to a military mess at the Cape of Good Hope ; another case was that of a 
soldier who had been also a long time at the Cape. 

16. Taenia acanthotrias, like the T. marginata, is only known in man as an 
embryo or cysticercus. From twelve to fifteen of them were found in the 



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186 



TOPICS RELATIVE TO PATHOLOGY. 



muscles of a woman about fifty years of age, by Dr. Jeffries Wyman, in 1845. 

Tlie' woman was a subject in the 
Fig- 28. dissecting-room at Richmond, 

Virginia. The rostellum of this 
parasite is furnished with three 
rows of hooks, fourteen in each 
row. 

17. Taenia flavopunctata meas- 
ures about eight to twelve inches 
long. The proglottides are short, 
and there is a yellowish spot, 
clearly visible to the naked eye, 
situated about the middle of each 
joint, which reminds one of the 
color and situation of the genital 
organs as seen in the Bothrioceph- 
alus. The reproductive orifices 
occur all along one side of the 
worm, and the eggs are unusual- 
ly large. Only one instance of 
the occurrence of this parasite is 
on record ; " it was obtained in 
considerable numbers by Dr. Ezra 
Palmer in Massachusetts, in 1842, 
from an infant nineteen months 
old. They were expelled without 
medicine, their presence not hav- 
ing been suspected (WisiSLAND, 
Cobbold). 

18. Taenia nana, when fully 
grown, attains a length of eight 
or ten lines, and carries from 150 

to 170 joints. Its hooks are essentially the same in form as those of other 
Tceiiia, only they are very minute, and have a peculiar form, owing to the 
close approximation of the claw and of the anterior root-process (Leuckaet), 
which gives them a "bifid" appearance. Its head is comparatively large and 
obtuse, with a long neck. It was firet described by Bilharz in 1851, having 
been found in Egypt in the intestine of a young man. 

20. The Taenia elliptica, whose cydkercne, or embryotic condition, is not 
yet known, is common to cats and dogs, and sometimes infests man (EsCH- 
Eicirr, Leuckap.t). Weinland believes that the eysticcrcns will be found in 
flies, and that dogs (jlitain the larvae by snapping at dipterous insects. 




l-lOOth of an inch X 23 diameters. 

ILead of the Tccnia -i}icdiocanellata, drawn from the cam- 
era lucida, by Assistant-Surgeon B. J. Jazdowski, from 
one of three specimt-ns, all of which were removed from 
tlie small intestines of a soldier who died at Fort Pitt in 
18G(I, and who had been for many years a cook at the 
Cape of Good Hope. Tlie specimens are in the Mnseum 
of tlie Army Medical School at ISctley. 



The tape-worms just noticed are all mature parasites, and for that reason 
they have been considered together. It therefore comes that number 14 of 
the list, at page 146, has been left to take its place amongst — 

Tlie Immature Tape-worms, Nonsexual, Cystic, or Vesicular Parasites. 

These entozoa arc variously spoken of by the older, and even by many 
recent writers on medical subjects, under the vague terms of hydatids, cysts, and 
acephalocysts. They all inhabit the closed cavities of animals, or they are 
inclosed in cysts in the more solid parenchyma of their organs. They are 
represented by the scolices or second stage of the tape-worm embryo, and cou- 
.sists of a Tauiia head, [)rovided with a similar circle of hooklets, Or absence 



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VARIOUS KINDS OF OYSTICERCI. 187 

of booklets, as the ease may be, according to tbe variety of the Tamia, and 
four oscula, and this head is united by a neck to a vesicular body of variable 
size. These are now known to be as already described, varied forms of ToBnice 
embryos, of which the following infest various parts of the human body, or of 
animals used as food, or of domestic animals not so used : 

14. The Cysticercus of the Taenia solium (synonym, Cydicercus telw cellu- 
losce) is the larva or scolex of the Tmnia solium, and as seen in man, in the pig, 
in the ox, horse, calf, camel, sheep, and roe deer, it consists of a vesicle — con- 
ical, glistening, and white — containing fluid ; to this a 'head is attached by a 
narrow pedicle or neck, which is transversely lined — the lines approaching 
to rugse towards the vesicle. Its size varies in solid viscera from that of a 
small pea to a large marble ; but in free cavities, such as in the ventricles of 
the brain, it attains a larger size. The smallest measles {scolices) measured 
has been j'j^th of an inch in diameter from the brain, liver, and intermuscular 
septa of a pig, thirty days after feeding with proglottides ; and the complete 
development is usually accomplished within ten weeks, when the cyst measures 
jth to §d of an inch, or from the size of a pea to that of a kidney bean. The 
cyst is more dense at the side or edge where the head and neck are growing, 
than at the great vesicular part, which is the vesicular or bladder-like end. 
The head and neck can be drawn, as if into the vesicle, so that the form and 
appearance of the parasite may thus be very much altered. An external 
cyst incloses the parasite when it inhabits a solid viscus, such as the substance 
of the liver, or amongst the connective tissue of muscle; but in close cavi- 
ties, such as the eye or the ventricles of the brain, there is no enveloping cyst, 
and the parasite floats free within the cavity. In these more free conditions 
it tends to grow more like the form of a tape-worm; and if it happens to be 
in the eye, it may soon destroy it, by fixing its hooks in some of its delicate 
textures. The cyst which envelops the parasite is developed at the expense 
of the tissue in which the parasite imbeds itself. They have been thus seen, 
in man as well as in animals, in the heart, liver, choroid plexus, the brain, in 
the tissue between the sclerotic and the conjunctiva, in the anterior and pos- 
terior chambers of the eye (Mackenzie), and in the retina (Geaefe). The 
head resembles that of the T. solium, and carries thirty-two hooks in two rows, 
and the neck varies greatly in length. The parasite is especially frequent in 
domestic swine, and in them it produces the appearance known as the 
"measles," or "measly pork." 

15a. The Cysticercus ex Taenia mediocanellata is to be found in the mus- 
cles and internal organs of cattle. For our knowledge of the larval state of 
the T. mediocanellata we are mainly indebted to Professor Leuckart, of Giessen. 
He has artificially reared them in the flesh of calves, from the eggs of a T. 
-mediocanellata ; and recent experimental researches incontestably prove that 
the " measles" of cattle give rise to the T. mediocanellata. He fed two calves 
with the fresh eggs of the T. mediocanellata, by giving them the proglottides 
of this parasite. The first animal he experimented on died from a violent at- 
tack of the measle disease ; and on dissection the muscles were found filled 
with measles, or vesicles containing imperfectly-developed scolices. On the 
second occasion a smaller number of proglottides (in all about fifty) were ad- 
ministered, and the febrile symptoms again appeared with such virulence that 
Leuckart thought this animal would die also. Fortunately, after the lapse of 
a fortnight from the commencement of symptoms, some abatement of the 
disease took place, and this gradually continued until the animal was per- 
fectly restored to health. Eight-and-forty days subsequent to the earliest 
feeding experiments (which were continued at intervals for eighteen days) 
Professor Leuckart extirpated the left cleidommtoid muscle of the calf, and 
whilst performing the operation he had the satisfaction of seeing the cysticercus 
vesicles lodged within the muscles. They were larger and more opalescent 
than those of the Cysticercus tcenia cellulosce, but nevertheless permitted the 

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188 TOPICS RELATIVE TO PATHOLOGY. 

recognition of the young worms through their semitransparent coverings. 
The heads of the contained aj?ticerd exhibited all the distinctive pecularities 
presented by the head of the adult Strohila (the T. mediocanellata). Taking 
the results of this experiment in connection with previously ascertained facts, 
the most unequivocal evidence is brought together that man becomes^ infested 
with the T. mediocanellata by eating imperfectly-cooked veal or beef in which 
the cystiaerci abound. 

21. The Cysticercus of the Tsenia marginata {Oysticercm tenuicollis) is 
rarely found in man, but it has occasionally been found in the mesentery and 
in the liver. Eschricht and Schleissner have shown that these Oysticerd are. 
sometimes associated with the Echinococcvs in Iceland (Cobbold, 1. c). It is 
only in this immature state that it is known to infest man as a oysticereus. 
The full-grown tape-worm is found in the dog and wolf, and is often con- 
founded with the T. aerrata, from which it differs in its comparatively bulky 
size and the peculiar form of its hooks. The proglottides nearly equal in size 
those of the T. solium. In its scolex or immature condition this parasite has 
a very wide distribution ; for, in addition to its occasional presence in man, it 
has likewise been found in various monkeys, in cattle and sheep, reindeer, and 
in many other ruminants ; in horses, swine, and even in squirrels. Its habitat 
is for the most part the peritoneum (Rose and others). The cysticerd occa- 
sionally attain an enormous size. 

22. The Echinococcus hominis is the larva of the T. eeJiinoeoecus ; and the 
first accurate description of the immature form of the parasite was published 
by Bremser in 1821. These parasites have been, and are still often indiffer- 
ently named "hydatids" or "echinococcus cysts ;^' but English writers have 
restricted the term " hydatid" to designate the enveloping cyst, and the term 
" echinococcus" to signify the contained entozoon. The Echinococcus is an ex- 
tremely common parasite of the human body. It has been found in the kid- 
neys, lungs, liver, brain, heart, spleen, ovaries, breasts, tissue of the throat, 
and the bones ; and they are not unfrequently discharged with the expectora- 
tion, or by stool.' In the Icelandic endemic disease due to this parasite there 
is scarcely a part of the body in which it has not been found ; and its occur- 
rence in Iceland is a remarkable example of the prevalence of cystic entozoa 
in the human subject. It appears that the people of that country have been 
for some time suffering to a great extent under this very remarkable hydatid 
disease, which mainly affects the liver, peritoneum, and subcutaneous texture. 
Eschricht, writing to Von Siebold, says, " The disease has extended itself to such 
an alarntiing degree, that about a sixth of the whole population of Iceland are 
affected with it, and that it is attracting considerable attention at Copenha- 
gen." It produces a long, protracted illness, terminating with a painful 
4eath, and means of cure have not yet been discovered. Von Siebold con- 
siders it " probable that this disease arises from the immense quantity of dogs 
kept in Iceland, for the purpose of herding sheep and cattle" (Schleissner, 
Medical Topography of Iceland ; Allen Thomson, I.e.; also Leared, in 
Medical Times, 1863). 

In some cases only a single " hydatid tumor" is developed in an organ or 
part ; but occasionally two, three, or more tumors may be found. These " hydatid 
tumors" consist externally of a firm fibrous capsule, of a tint which varies with 
the organ in which it may be developed. In the liver they are white, or of a 
yellowish tinge. The capsule adheres intimately to the surrounding tissue, 
-and is abundantly supplied with bloodvessels. Bands of connective tissue 
may be seen stretching outwards from the capsule, and incorporating it with 
the tissue in which it is imbedded. Within this capsule, and completely fill- 
ing it, are — (1.) A gelatinous, translucent gray bladder or bladders, composed 
of numerous concentric hyaline layers, giving a laminated appearance to a 
section. It is finely granulated in some parts (degeneration?) and highly 
elastic. (2.) A very thin and delicate membrane is spread over the interior 

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DESCRIPTION OF BCHINOCOCCUS EMBRYO. 



189 



of this elastic hyaline bladder, as the innermost layer of the "hydatid tumor." 
This membrane is the mother sac of the Eckinococcus embryo (Huxley), and 
corresponds with the germinal membrane of Professor Goodsir. It is studded 
with innumerable transparent cells, varying in extremes of measurement from 
jTjVjjTTsth to ^5 jjn*^ of ^^ inch. It is the seat of the development of innume- 
rable iMdnocoeai ; and to this membrane, in a fresh hydatid tumor, they are 
found connected by a delicate membrane, either singly or (more commonly) 
in clusters, the number of individuals on the cluster varying from ten to a 
hundred or more, as shown in the annexed woodcut (Fig. 29). 




Groups of Echinococci, showing — (1 ) The pedunculated connection between these parasites and the 
germinal membrane ; (2.) Their occurrence in groups, enyeloped by a very delicately thin membrane, 
continuous with the germinal membrane (after Erasmus Wilson). 

On close examination with the naked eye these groups present the appear- 
ance of a number of delicate white particles upon the inner surface of the 
germinal membrane ; and when the aggregation into groups consists of many 
individual embryos, they may be seen through a transparent cyst. They are 
the soolices or embryos of the T. eckinococcus in various stages of development. 
The " hydatid tumor " is filled and distended with a clear watery fluid, with 
numerous large and small vesicles, more or less clear and transparent, float- 
ing free, or so closely packed together that they cannot be removed without 
some degree of pressure. Some of them, particularly the smallest, adhere 1o 
the germinal membrane. They vary in size from that of a millet-seed to a 
size as large as a goose's egg, and their number not unfrequently amounts to 
several hundreds (560, Pemberton), or even thousands (7000 and 8000, 
Allen, quoted by Ploucquet and Feeeichs). The larger of these free vesi- 
cles sometimes contain smaller ones of a third generation, and occasionally 
they in their turn contain others of a fourth generation. The size of the 
" hydatid tumor " and the germinal membrane must increase and grow accord- 
ing to the number and size of the daughter-vesicles, and in proportion to the 
quantity of contained fluid, which is sometimes 
rendered slightly opaque by the quantity of em- 
bryo Eehinococd floating free in it. From the 
rotundity and distension of these inclosed vesi- 
cles it is difficult to fix them for examination ; 
and when they are punctured, their fluid con- 
tents issue from the vesicle in a jet of considera- 
ble force, impelled by the contractile power of 
the elastic tissue ; and if the incision be of a 
sufiicient size, the vesicle will roll up, and turn 
itself inside out. The Eohinococeus embryo va- 
ries in size from Jjth to ij'j^th of a line in length 
in the contracted state, and from J|,th to J^th 
of a line in its elongated form. These varia- 
tions in length are according as the head of the 
parasite is extruded or retracted within the vesicle. The contracted state, in 
which the head is retracted within the vesicle, is the form most commonly seen 



Fig. 30. 




Two Echinococci from a " hydatid 
tumor." The one has the head re- 
tracted within the vesicle ; the other 
has the head extruded. 



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190 



TOPICS RELATIVE TO PATHOLOGY. 




(A.) An Echinococcus 
viewed transversely, the 
head being directed to- 
wards the observer ; s, s, 
suctorial discs. The hook- 
lets are seen to encircle a 
membranous disc. 



the hook, and has 



in the "hydatid tumor," after removal from the organ in which it was devel- 
oped. In this state it is usually globular or oval, and slightly flattened at the 
opposite poles. In the elongated state, when the head is extruded and the 
hooks appear outside, the parasite is usually larger at the cephalic end, where 
there may be seen four suctorial prominences and the circlet of booklets. 

The Echinococci vary much in regard to the number' of cephalic booklets 
they display at certain intervals of growth, but not sufficiently to give ground 
for specific distinctions to be made amongst them ; and 
while the number of hooks fluctuates in all the forms of 
Echinococci that have been described, the alleged dif- 
ferences in the size and character of these booklets have 
reference to the degree of development of the parasite 
(Leuckakt, Cobbold). The.se hooks are arranged in 
a double festoon, round a membranous disc (Fig. 31, 
A), and vary from twenty-eight, thirty-four, forty-six, 
or even fifty-two. They are arranged in two rows (Fig. 
32, B), one row containing longer hooks than the 
other ; the longer ones measuring about TiiVirth of an 
inch. They each possess a gentle curve, so that there 
is a concave and a convex border, and a base (Fig. 32, 
b, c) which encroaches on the concave border for nearly 
half its length. The base is broader than any part of 
bifid end. These booklets move on the central bifid 
process as on a pivot (Fig. 32, f, g, A). Hook sacs may be distinguished with 
a sufficiently powerful lens. These booklets are 
Fi'^- 32. of so minute a size, and at the same time so ex- 

tremely characteristic and important in diagnosis, 
that the annexed woodcuts (Figs 31 and 32, after 
Erasmus Wilson) may give an idea of their shape 
and arrangement. 

The head of the worm is separated from its body 
by a groove, and at its opposite pole is an um- 
bilical depression, which gives insertion to the 
peduncle which fixed it to the germinal membrane 
(Fig. 30, a). 

As the growth of the " hydatid tumor " ad- 
vances, the- external enveloping capsule gradually 
loses its uniform thin and smooth character. It 
becomes rigid, fibrous, or even cartilaginous, while 
its inner surface becomes rough and uneven, cov- 
ered here and there with laminated deposits. Fre- 
richs, of Berlin, has seen such capsules completely 
surrounded by a calcareous shell ; and the thicker 
and more rigid the capsule becomes, the greater 
is the resistance opposed to the further growth of 
the Echinococci, which may even be thus arrested, 
so that the parasites die, and a spontaneous cure 
results (Gruveilhier, Feeeichs). 

Compound " hydatid tumors " have been found 
in which the cavity is multilocular. Outgrowths 
or buds form, which give an alveolar character to 
the lesion (Buhl, Viechow, Feeeichs) ; and 
such occurring in the liver (as in several specimens 
in the museum at Netley), show on section a most peculiar alveolar appear- 
ance, the alveoli varying in size from that of a pin-head to a pea, and lined 
by the characteristic cyst. 

It has been usual to consider that there are two distinct forms of Echino- 




(B,) The circleof hookletsseen 
upon its under surface ; thirty- 
four in niiniber, seventeen long 
and seventeen short. (C.)b,c, 
Lateral views of the separate 
booklets— /.(, The base ; c, The 
central extremity, or bifid pro- 
cess of the base ; c, Hooklets 
viewed upon the concave or in- 
ferior border ; /, <7, k, A diagram 
illustrating the movements and 
position of the hooklets. The 
■dotted line represents the outer 
surface of the neck, and runs 
through the fixed point of the 
ihree hooks. 



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NATURE OF ACEPHALOCYSTS. 191 

coceus cysts severally referable to different tape-worms ; but they are now re- 
garded as one and the same. The cysts so prevalent in Iceland are known to 
occur indifferently in men and oxen ; and are sometimes so prevalent that 
about one-eigtth of all the cases of disease are referable to this cause; and 
generally several members of one family suffer (Leared). The Tcenia echi- 
nococcua is very often seen in Iceland. It is a very small one, consisting of 
not more than three or four segments, and not much longer than a line, 
and carrying twenty-eight to thirty-six booklets. It is found in large numbers 
in the intestines of dogs. 

Acephalocysts require some notice here. They were first described by 
Laennec as growths of membranous cysts. In the present state of science 
they are regarded as abortive Cysticereus or JSchinococcus cysts — ^parasites of 
one or other of those kinds in which the development has been arrested. Re- 
mains of booklets have been found in them ; and the structure of the cyst 
may sometimes be seen to be precisely similar to that of the Echinoeocciis cyst. 
They have been found in all those places where the Qysticerd and Eohinoooceus 
cyste are known to abound — e. g., liver, spleen, kidney, bladder, and in exos- 
toses of bones. 

Thus we have seen that each kind of Tmnia has not only its own definite 
vesicular embryo, but each Tmnia has a definite Cysticereus or Echinococcus ; 
and all of them are capable of being developed or reared into Tmnia when 
transferred into the alimentary canal of a suitable animal ; and conversely, 
the development of Oysticercus and Echinococd occurs in man and other ani- 
mals in consequence of segments of tape-worms, or the ripe ova they contain, 
being eaten with their food. 

The experimental proof of these statements it is the principal scientific merit 
of Kuchenmeister to have established, by experiments which' date so far back 
as 1851 ; and they have since been repeated and confirmed by many other 
observers (Siebold, Nelson, Zenker, Leuckart, Weinland, Knoch). 

The experiments of Kuchenmeister were made on a variety of animals, and 
in one instance on the human body. The following is a short summary of 
his observations, together with those of Von Siebold and others, condensed 
from Dr. Allen Thomson's valuable paper in the Glasgow Medical Journal, 
No. X, July, 1855, which demonstrates the 

Relation betiveen the Oystic and the Cestoid Entozoa. 

Experiments to determine this relation mainly consist in observing the 
effects of feeding an animal with the ova or-larvse with which it is designed to 
affect it and other animals with the cysts. 

The first experiment of this kind was performed by Kuchenmeister in 1851. 
He caused young dogs to eat with their food a number of the Cysticereus pisi- 
formis of the rabbit and hare, and found that after some weeks these Cystieerei 
were converted, in the intestine of the dogs, into the T. serrata. 

The more important of the experiments devised and performed by Von 
Siebold confirm these results, and are described by him in his Essay on Tape- 
worms. They may be arranged as follows : 

First Series. — Ten young dogs were fed with the C. pisiformis from the 
rabbit, and being killed and opened at different successive periods afterwards, 
the gradual progress of conversion of the Cystieerei into Tcenice was carefully 
observed in their intestines. It appeared that, by the action of the gastric 
fluid in digestion, first the cyst and then the caudal vesicle of the Cysticereus 
were dissolved in the dog's stomach ; but the head and neck, resisting entirely 
the solvent action, passed into the duodenum. Here they soon became attached 
to the mucous membrane : and after an interval of only two or three days 
they were seen to enlarge, the head and neck undergoing little change, but 
the body elongating and transverse grooves appearing, which afterwards 



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192 TOPICS RELATIVE TO PATHOLOST. 

became more marked, and divided the body into segments. In less than two 
months these TcB7ii(B had attained a length often and twelve inches ; in three 
months they were from twenty to thirty inches long, and the reproductive 
organs were fully developed in the last or caudal segments, which then began 
to separate as proglottides. 

Second Series. — These experiments were made by feeding young dogs with 
the C. tenuicollis, which is common in domestic cattle, and of which the vesicle 
often attains a large size. Having found that the vesicle was invariably de- 
stroyed by digestion. Von Siebold contented himself thereafter with giving the 
heads only to the dogs, removing artificially the vesicle. Six young dogs 
were the subjects of this experiment, which was conducted in a manner similar 
to the first, and with the same result— namely, the formation of tape-worms, 
which reached their full development in forty-eight days, and corresponded 
exactly with T. serrata. 

Third Series. — In this set of experiments the C. ceUulosce, from the flesh of 
the hog, was employed. Four young dogs received at different times a num- 
ber of these Cysticerei with their food, and on being opened at different inter- 
vals afterwards, tape-worms, which resembled exactly the T. serrata,^ were 
found in their intestine, in various stages of advancement corresponding to 
the length of time that had elapsed. Von Siebold was struck with the close 
resemblance of this T. serrata of the dog to the common T. solium of man, and 
after an accurate comparison of various examples of these entozoa, concludes 
that' they are identical, and not to be specifically distinguished, or that at 
most they are varieties of the same species, dependent only on the difference 
of their parasitic habitations. 

Similar experiments have since been made by Leuckart, and repeated by 
Cobbold, as to thfe cysts in cattle — the Oysticercus Taenia mediocanellata. 

Fourth Series. — ^This series of experiments was performed in the same man- 
ner as the last, but with the heads or scolices of the Ccenurvs cerebralis, the 
entozoon so well known in connection with the disease called "sturdy" and 
"staggers," which it produces when infesting the brain of sheep and cattle. 
In order that the Cmnurus might be procured alive, the dogs experimented 
on were carried to a part of the country where a number of sheep were 
affected with the "sturdy." In the intestine of five out of seven dogs fed with 
the Ccenurus, great numbers of Tmnirn were found, at successive periods and 
in different degrees of advancement; in thirty-eight days the Tmnice had 
arrived at maturity, and appeared, like those in the previous experiments, to 
correspond exactly with T. serrata and T. solium; in two other dogs the ex- 
periment was rendered nugatory by the dogs being ill of distemper at the time. 

Fifth Series. — The last of the experiments related by Von Siebold were 
made with the Eehinoooccus animaleules of domestic cattle, which are not 
specifically different from those of man. As many as twelve young dogs, 
and also a fox, received a quantity of the small Eohinoeocd in milk ; and on 
being examined at various periods from the commencement up to twenty-six 
days, there were found, in all different stages of development, small Tmnice 
totally different from any observed in the previous experiments, or indeed 
from any accurately distinguished or described by helminthologists. Von 
Siebold proposes to call this variety T. echinococcus. It is remarkable for its 
very small size — not much longer than an inch ; and for the small number of 
its joints — which never amounted to more than three ; and for the circum- 
stance that the reproductive organs are confined to the two last segments, and 
the caudal joint separates as a proglottis at a very early period. 

The Experiments on Man may be looked upon as the most interesting of all. 
Having the opportunity of repeating on a condemned criminal the experi- 
ments which he had previously performed on animals, Kuchenmeister con- 
trived to give to this man, at seven successive times, between 130 hours and 
12 hours previous to his execution, mingled with various articles of food, a 

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EXPERIMENTS OF LEUCKART AND COBBOLD. 193 

number of Gysticerd from the hog and some from the rabbit. "They appear 
to have been partly disguised by their resemblance to the grains of rice in 
.warm rice soup ; partly by their likeness to the small bits of paste in a kind 
of vermicelli soup ; and partly foisted on the unhappy wretch by being sub- 
stituted for the small lumps of fat in blood-puddings" (Brit, and For. Med- 
Chir. Review, Jan., 1857, p. 119). After death, a number of young Tcenice, 
in different stages of advancement, were found in the intestine ; the greater 
number of them loose, but a few attached to the mucous membrane. The 
form of the booklets, and other circumstances, induced him to regard these 
tape-worms as the T. solium. There were no traces of the Oysticerd last 
swallowed; and Kuchenmeister was of opinion that those only which were 
first taken, and which were quite fresh, had been converted into Tcenice, and 
that those taken later, being dead, had been digested with th^ food. Leuckart 
made a similar experiment. He fed a man thirty years of age with Oysticerd 
from a pig, and in two months the man had Tcenice. But the enthusiastic 
and skeptical Germans were not yet content with the proof. M. Humbert, 
of Geneva, experimented on himself On the 11th December, 1854, he 
swallowed fourteen fresh Oysticerd in presence of MM. Vogt and Moulinie ! 
Early in March of 1855 he felt the presence of Tcenice, and discharged seg- 
ments of them. 

With regard to the converse experiments, the following facts may be related : 

Kuchenmeister, having previously caused the production of the T. serrccta 
in a dog, by feeding him with the 0. cerebralis from a sheep, gave to young 
lambs some of the ripe joints or proglottides of this Tcenia, and by the 
fifteenth day the usual symptoms of sturdy began to appear in the lambs. 
Kuchenmeister sent some of the same Tcenice to Van Beneden at Louvain, to 
Eschricht at Copenhagen, and to Leuckart at Giessen, all of whom, in sepa- 
rate experiments, caused lambs in the same manner to take the Tcenice seg- 
ments with their food, and in all the cases the same result followed — namely, 
the occurrence of the symptoms of sturdy at a period of from fifteen to 
eighteen days after the mature segments of Tcenice were given. Twenty-four 
hours after administration, the blood of the portal and other abdominal veins 
contained numerous cestode embryos. On the fourth day, semitransparent 
vesicles, g'gth of an inch, appeared in the liver, and in six days they measured 
j'jth part of an inch. The same experiment had likewise been performed by 
Dr. Haubner, of Dresden. He caused six young lambs to swallow the living 
and mature segments of a T. serrata. They all died of the vertiginous disease; 
and the Ooenurus cysts were found in the brains, heart, lungs, and voluntary 
muscles. The symptoms commenced by the fifteenth day; and in point of 
time their appearance was curiously constant, the vertigo being obvious 
between the fifteenth and eighteenth days in all the experiments. 

Several of these experimenters, having examined carefully the lambs so 
affected, were able to detect the progressive stages of formation of the Ooenurus 
in the cortical substance of the brain, where alone these entozoa seemed to. 
attain the true Ocenurus form. There were abundant traces of them in the 
heart, diaphragm, and other muscles, and also under the skin, in some of the 
experiments; but in these situations they appeared to be abortive; while in 
the brain they gradually grew, and in some instances the vesicle had there 
attained the size of a hazel-nut. The brain was in all instances marked with 
inflamed grooves over its surface, indicating probably the track of the Tcenia 
embryos; for at the end of each of these tracks, in the early stages, were 
found the minute Ccenurce. 

Another confirmation of the fact of the conversion of the ova of Tcewm into 
cystic entozoa has been afforded by an experiment of Leuckart's, which merits 
separate mention. It gives the complement of the relation between the 0. 
fasdolaris of the mouse and the T. crasdcollis of the cat. Having in his pos- 
session a family of white mice, which he had employed for various experi- 

VOL. I. 13 

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194 TOPICS RELATIVE TO PATHOLOGY. 

ments, and in none of which had the Cystieereus of the liver been perceived^ 
he gave to six out of twelve, with their food and drink, the ova of the T. 
crassicoUis, obtained by breaking up the ripe joints or proglottides of this tape- 
worm from a cat. Four months afterwards he found, on opening these mice, 
that four of them were affected with the C. fasdolaris of the liver ; and he 
ascertained that in none of the mice which had not received the Tcenia ova 
was there any production of these entozoa. Similar experiments have been 
made with Tcenia solium and T. mediocanellata. 

From the whole series of observations and experiments that have now been 
made, and of which a summary has been here given, the following general 
conclusions may be drawn and elementary facts stated, namely: (1.) That 
entozoa are always introduced into animals from without ; (2.) That some 
obtain access to ,the body of animals from water, or other matters in which 
they have previously lived in the free condition, while others are taken along 
with animal food in which the entozoa have lived parasitically ; (3.) That 
entozoa, when reaching sexual perfection in their parasitic condition, require 
to be in a situation which communicates with the external air — the most 
common position being the alimentary canal, and more rarely the pulmonary 
cavities ; (4.) That almost all the entozoa inhabiting close cavities, or other- 
wise encysted in the bodies of animals, are only imperfect and earlier forms 
of other entozoa, which may attain maturity in the open cavities of the same 
or of different animals, or in the fi-ee condition, that is, liberated from their 
cysts; (5.) That entozoa rarely propagate themselves in the same animal in 
which they have arrived at sexual maturity, but require a different habita- 
tion, which they reach by migrations in the various modes before referred to ; 
(6.) That the cystic entozoa are the imperfect states of different TcenicB ; (7.) 
That Tcenia are almost invariably introduced, in their earlier condition, into 
the bodies of animals with flesh or other animal food ; (8.) That if the ova of 
Tcenice be introduced into the alimentary canal of a suitable animal, through 
water, vegetable food, or fruit, their tendency is, after penetrating the tissues, 
to become encysted, and to assume the form of a cystic entozoon, such as that 
of a Oysticercus, Ccenurus, or Echinococcus ; (9.) That if these cystic entozoa 
again are taken by certain animals with their animal food, the head part 
(which corresponds with that of a Tcenia) resists digestion, and has a tendency 
to establish itself, and become developed into some form of Tcenia in the 
alimentary canal, by the formation of segments after attachment to the 
mucous membrane. 

The prevalence of cysts in the ration-beef served by the Commissariat 
throughout the Punjaub, especially at Peshawur, Meean Meer, and JuUun- 
dur, has, for many years, challenged the attention of the authorities. I have 
had a sample recently sent me from Meean Meer of this beef, containing as 
many as 100 cysts in the pound of flesh ; and the medica,l ofiicer who sent it 
me has taken out as many as 300 to the pound of ration-flesh. The largest 
.percentage of cyst-infected cattle occurred in the Lahore division of the Pun- 
jaub, in January, 1869, namely, at Meean Meer, where it was as high as 
33.15 per cent. ; and next in Peshawur, in February, 1869, when it was 17.99 
per cent. But all statements regarding the number of slaughtered cattle 
^^^ gg rejected as food, on account of being cyst-infected, are 

extremely variable, and are totally worthless as to 
■ ^ scientific value. No two inspectors are equally care- 
ful, and great differences exist as to the practical 
knowledge and experience of examiners individually ; 
while the general ignorance on the subject of such para- 
o/a;*^clJr™?riJ^r- ^^^es and their propagation is almost incredible. The 
caneuata, natural size. natural Size and appearance of these cysts are repre- 

sented (Fig. 33) by a and b. The head of one of these 
is magnified in Fig. 34, to the extent indicated by the scale attached, and is 

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CYST-INFECTED RATION-BEEF IN THE PUNJAUB. 



195 



shown to be the characteristic head of Tcenia mediooanellata in its embryo 
state. It may be contrasted with the embryo head of Gydicercus telce cel- 
lulosm of measly pork (Fig. 35). Up to August, 1868, a great destruction of 



Fig. 34. 




Head of Cysticercms Tcsnia mediooanellata from ration-beef. 



Fig. 35. 



ration-beef had taken place in India, on account of these cysts; and 17,428 
pounds of meat had been destroyed in 1868 and 1869. The Government 
then appointed Assistant-Surgeon Cleghorn to investigate into the whole 
question. The extensive condemnation of meat on account of cyst thus in- 
curred great expense to the Government, so 
great that the Commissary-General feared 
a difficulty might be experienced in pro- 
curing the number of cattle required for 
rations. The Inspector-General of Hospi- 
tals, Dr. Muir, also expressed his belief that 
the danger of eating cyst-infected beef 'had 
been much exaggerated, and that it might 
be eaten with safety, provided it was thor- 
oughly cooked. The Commander-in-chief in 
India concurred in this view, and orders 
were accordingly issued by the Government 
to this effect. Further special inquiry was, 
however, suggested, but was deferred ; till a 
Eeport, dated' June 1, 1870, by Assistant- 
Surgeon Oliver, R.A., on the prevalence of 
cysticercus in ration-beef at Jullundur, was 
considered by Dr. Muir to confirm his 
opinion, and was no doubt satisfactory to 
the authorities, and especially to the Commissary-General (Abstract of Pro- 
eeedinga of the Sanitary Commissioner with the Government of India, August, 
1870, p. 236). 
Dr. Oliver reports that the whole of the meat was well-fed, and of excellent 




Head of D. Cpsticerctis cellulose from measly 
pork, V. contrast with the Tcenia mediooanel- 
lata. 



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196 TOPICS RELATIVE TO PATHOLOGY. 

quality ; and the objects of his inquiry were, — (1.) As to the sources whence 
the cattle obtained the Tcenia ova ; (2.) As to whether or not any evil results 
followed the consumption of cyst-infected meat when properly cooked. 

Regarding the source of the Twnia ova, it was found, — 

(1.) That the infected cattle had been purchased by native dealers from 
various parts of the district, not from any particular locality. 

(2.) That when brought in they were lean, and, on an average, required 
from two to three months' feeding at the Commissariat cattle-yard before they 
were fit for the shambles. 

(3.) That their food consisted of the (/ra,ss they eouM pick up on the grazing- 
grounds of ecmtonments, supplemented by such an allowance of grain and 
bhusd as their condition required. 

(4.) They were supposed to be watered at a trough with water drawn from 
a well, but it transpired that they very frequently were taken to a large dirty 
tank near the yard for their water. 

There can be no doubt, from the above statements, that both the grazing- 
grounds of the cantonments and the dirty water of the tank were plentiful 
sources of Tcenia ova. The tank was close to the huts of the camel-drivers, many 
of whom ivere infected with Tcenia medioeanellata. Human filth ivas often to be 
seen on the hanks of the tcmk, and microscopic examination of such, and of stag- 
nant wcder taken from the margin, exhibited Tcenia ova. 

Dr. Oliver also says, that, a few months after means were taken to secure a 
good supply of well-water for the cattle, cysticerci entirely disappeared from 
amongst them. The cysts are most abundant in the flesh at the root of the 
tongue, also in the flesh of the rump, and the psoas muscles, the gluteal and 
lumbar regions ; but it is not possible to detect them for practical purposes 
before death in any of these situations. 

Besides the ration-beef cyst, the wateiy-bag or hydatid cysts largely infest 
the animals killed at the Commissariat slaughter-house. Of the livers, 70 per 
cent, were so infected (Oliver and Cleghoen). As these cysts or watery- 
bags are only seen in the internal parts, the attention of medical ofliicers has 
not been so much directed to them. Hence a prominence has been given to 
ration-beef with cysts, rather than to the abundant existence of watery-bags 
or hydatids, which have been in some measure overlooked. The liver and the 
lungs are the parts generally infected. The larger of the hydatid cj^sts are 
found in the liver, — from a pea to a man's head in size. They are the inclos- 
ing bags of the embryo echinococcus — a little tape-worm, which infests the dog 
tribe (see p. 188, ante) ; and considering the immense number of Pariah dogs 
which Dr. Oliver says are fed on the refuse of animals infected with hydatids, 
there can be no doubt about the source of the water-bag infection of cattle. 
The ova of the Tcenia echinococcns passed by the dogs must be extensively 
disseminated over the pastures on which the cattle graze. The refuse of 
animals infected with watery-bags ought to be burned. No dog should be 
allowed even a smell of such offal. 

Dr. Oliver's experiments as to eating beef infected with cysts show, as the 
experiments of otliers have long ago shown, that if the vitality of the cysts is 
destroyed by a high temperature, it will not produce tape-worm ; but if the 
flesh is underdone, or if "scolices" of cysticerci are surreptitiously introduced 
into the food of a Hindoo boy of low caste (or any other boy), the chances 
are, that between three and four months afterwards, that boy will apply (as 
the Hindoo boy did), for tape-worm medicine. Surely such experiments are 
not now required ? 

Tfmia medioeanellata is acknowledged to be very common amongst the 
Mussulman pojiulation of the Punjaub, the lower classes of whom are in the 
regular habit of eating half-cooked beef — indeed, prefer it so. It is amongst 
these people that tape-worm is so prevalent. Dr. Oliver is of opinion, from 
his experiments and observations, " that the question as to the safety or other- 

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POWER OF PREVENTING CYST-INFECTION OF BEEP. 197 

wise of eating cyst-infested beef, simply depends upon the manner in which it 
is cooked. If this meat is thoroughly done, and presents no rawness when cut 
into, the measles appear like little nodules of coagulated albumen, are doubt- 
less perfectly inert, and may be eaten with impunity. But," continues Dr. 
Oliver, " it is not only thorough cooking that is required to guard soldiers in 
India from the ill effects of eating measly meat. There is a want of cleanli- 
ness in the general arrangement of the kitchens, and serving of meals, which 
must offer great facilities for the introduction into the food of eysticercus ; bar- 
rack cooks, unless constantly looked after, are utterly careless as to the 
washing of chopping-blocks, tables, dishes, &c. The dish or pot cover on 
which the meat is placed when raw is often used without washing for serving 
the piece up for dinner ; and I have myself picked up a eysticercus from the 
table on which a cook was preparing food." The dangers, too, of the parasite 
being conveyed by the cook's unwashed hands to the plates in which the 
meals are served, and the common practice of using the same knife for cutting 
up meat, and afterwards (without washing it) for other culinary purposes, 
must not be overlooked. 

With good selection and carefiil feeding, there seems to be every proba- 
bility that eysticercus would soon almost or completely disappear from our 
commissariat cattle. If they were entirely stall-fed, and watered from wells, 
there could scarcely be a possibility of infection after their purchase, and no 
possibility whatever if all ova-infested excreta were also destroyed. 

Notwithstanding the very excellent Report by Dr. Oliver, of June 1, 1870, 
the Sanitary Commissioner with the Government of India does not rise to the 
occasion. He merely observes that "it is very desirable that the special 
attention of the Executive Commissariat officers should be drawn to the great 
importance of being careful about the water used by slaughtered cattle." 
Moreover, he writes that " very little is yet known of these cysts or their con- 
nection with tape-worm," and suggests a careful inquiry, without arousing 
any alarm or suspicion. But with all due deference to the opinion of the 
Sanitary Commissioner with the Government of India, there is no fact in 
medicine more clearly and securely established, alike by experiment and 
observation, than the connection of such cysts with tape-worm, and of the ova 
of tape-worm with such cysts. Knowing this, and having seen every year, for 
the last ten or twelve years, the deficiency of practical acquaintance with the 
great facts of parasitic disease amongst medical men, I am compelled in duty 
to teach doctrine opposed to the practice prescribed for adoption in India. 

By the evidence contained in the abstracts of proceedings of the Sanitary 
Commissioner, it appears that so soon as the feeding and watering of the 
cattle are cared for in the proper manner, the cyst-infection of beef disap- 
pears. It is to this careful feeding and watering, therefore, that the Execu- 
tive ought to turn its attention and endeavors. Because the Executive fails 
to secure this cleanliness, is it politic that the cyst-infested beef-ration should 
be ordered to be used as food eveji when thoroughly cooked f It is by no means 
a settled question what amount of heat or cold is necessary to destroy the 
vitality of cysts like the eysticercus or echinoooccus (see Owen and Rudolph's 
observations at pp. 151, 152, ante). It is generally believed that the boiling 
temperature of 212° Fahr. is sufficient to destroy the vitality of these cysts, 
and to convert them as Dr. Oliver describes, into nodules resembling albu- 
men. But the boiling-point is not the ordinary temperature at which good 
wholesome meat is usually cooked, if it is well cooked so as to retain the 
nutritive juices in its interior. The outside may approach that temperature, 
and may even reach it in baking or roasting; but 158^ to 170^ Fahr, is about 
the usual range of temperature at which meat is cooked in perfection, so as 
not to be hard or shrunken. Apart from the disgust, discomfort, and disease 
to the soldier, the mere permission to use cyst-infested ration, and far more, 
the authoritative order that it must not be condemned, but eaten when 

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198 TOPICS KBLATIVB TO PATHOLOGY. 

thoroughly cooked, open a door for the wide extension and continuous propa- 
gation of these parasites — a door that ought to be most rigidly closed. The 
tendency undoubtedly is to undercook animal food rather than thoroughly 
to cook it, or overdo it. Thus greater facilities are afforded for such cysts to 
live and become tape-worms, capable in their turn of shedding myriads upon 
myriads of ova, which may find their way into other cattle and herbivora 
grazing on foul cantonments, and drinking the tsenia-ova-infested water of 
the tanks. Compare the ultimate and inevitable consequences of this policy 
with the policy of destroying all cyst-infected meat, and the incidental loss at 
first of 8000 or 10,000 pounds of meat in a year (the average j^early amount 
destroyed for 1868 and 1869) at 6d., or even Is. a pound, and the certainty 
that every year the loss would be less, and such parasites eventually stamped 
out, if care be taken as to the feeding and watering of the cattle, and destruc- 
tion of ova-infested excreta. 

Cyst-infested ration-beef, and all hydatids or watery-bags, ought to be wi- 
compromisingly condemned to destruction by fire; for there can be no doubt that 
parasitic disease has a firm hold, and is most disgustingly prevalent, among 
the inhabitants of India (both man and beast), and especially in the district 
of the Punjaub (see subsequent remarks by Dr. Gordon). I believe it to be 
increasing, not only from accounts I receive from India, but from the preva- 
lence of tape-worm {mediocanellata variety) in the intestines of invalids from 
India who happen to die at Netley, and in whom the existence of a tape- 
worm during life was unknown. As a rule, patients do not complain of tape- 
worm ; and unless they happen to be in hospital for other diseases, the medical 
officer has little chance of knowing how prevalent tape-worm may be among 
the men of a regiment. If the medical officer desires to know this, he must 
make a special inquiry, and with his own eyes must look for the presence of 
tape-worm links (proglottides) in the daily fecal evacuations of every man. 
A medical officer who did this amongst the patients in the hospital writes me, 
that he found six men out of thirty (one-fifth) suffering unknowingly from 
tape-worm when he examined specially to determine the point. How many 
cases were outside hospitals in India, there are no records to show. The prac- 
tical importance of this fact is obvious. All such ova-infested excreta ought 
to be as uncompromisingly destroyed by fire as the cyst-infested ration or 
hydatid. If such excreta are not destroyed, the ova inevitably find their way 
on the grazing-grounds of cantonments, or by surface conduits and drains into 
the water of tanks. 

If, on the one hand, cyst-infested beef is suffered to be eaten, and, on the 
other hand, the excreta of tape-worm infested men are allowed to go unde- 
stroyed, the propagation of parasitic disease broadcast over the land of India 
must be the inevitable result. Prophylaxis, therefore, is all-important; and 
the entrance of the scolices must be prevented. 

With prophylaxis in view, therefore, the following remarks are not less re- 
volting than suggestive. Dr. Gordon, of the Army Medical Department, 
thus writes : 

" Taenia appears to be of very frequent occurrence among the white troops 
in Upper India, and especially the Punjaub; and I have been told by some 
medical officers who have been stationed at Peshawur, our nearest canton- 
ment to Affghanistan, that they firmly believe every third soldier has had 
tape-worm during the two years regiments remain there. 

" From what I have been able to ascertain on the subject, natives are not 
particularly liable to tape-worm, and certainly not more so in the northv^est- 
ern parts of India than in Lower Bengal. This is generally attributed to their 
almost total abstinence from animal food ; and when we consider that both 
Hindoos and Mussulmans — all except the very lowest classes — abhor pigs' 
flesh, while our own countrymen are very partial to it, and the common sol- 
dier probably not very particular regarding the early history of the animal 

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CUSTOMS IN INDIA FAVORABLE TO PARASITISM. 199 

that is converted into pork for his use, an additional circumstance in favor of 
the transformation of tlie Oystioercus constituting the 'measles' of pork into 
Tcenia is thus disclosed to us. 

" Those who have escaped the misfortune of having had to pass some years 
in India can form no idea of the vast herds of lean, half-starved pigs that 
roam over the fields and waste grounds in the vicinity of villages ; neither can 
they have any conception of the nature of the food on which these pigs subsist. 

"The natives of India perform their ordinary natural functions in the open 
air on a piece of waste ground, left for the purpose on the outskirts of every 
village, and where, morning and evening, men, women, children, and pigs dot 
the ground at short intervals from each other. In an incredibly short space 
of time after the villagers have left the field it is as clean as if they had never 
been there, while the herd by which the clearance has been effected may be 
found in some shady place near or close to a tank, with the exception of a few 
of the more insatiable, that have gone to hunt for dead dogs, cats, cattle, and 
Hindoos that have paid the debt of nature since the previous meeting, and 
have been thrown or left on the plain to be devoured by domestic animals or 
vultures. 

" Pigs, however, are not the only animals that live in this filthy manner in 
India ; cattle and sheep, that are so particular in their food in Britain, 
acquire degenerate tastes in India ; and it is needless to enter into similar par- 
ticulars regarding ducks, fowls, turkeys, and pigeons, all of which are more or 
less used as food by our countrymen there. 

" I have thus alluded to these matters with a view to indicate some circum- 
stances that most unquestionably tend to vitiate the quality of the animal 
food upon which our troops in India must subsist, and I think I have at least 
shown a sufficient cause for almost any amount of disease in the bodies of 
these animals ; as also why their flesh should be more liable to become diseased 
in Upper India than in Lower Bengal " {Med. Times, No. 357, May, 1857). 

Abstinence from the practice of eating raw meat is to be strenuously recom- 
mended ; and cases closely inquired into will often be found to take their ori- 
gin from the habit of taking animal food imperfectly cooked or underdone. 
Children have been afiected with Tcenia on being, weaned, from the custom of 
giving them pieces of pigs' flesh to suck in an uncooked state, and containing 
Oysticerd. Cooks and butchers are known to be more liable than other peo- 
ple to be infested with tape-worms ; and in countries where raw or uncooked 
meat in the shape of fish, flesh, or fowl is much used, there tape-worms greatly 
abound, e. g., Abyssinia. By contrast, this is remarkably brought out in that 
countiy. it is observed that those who abstain from flesh altogether in those 
countries are altogether free, e. g., the Carthusian monks of Abyssinia. 

Vegetables eaten green, such as salads, ought to be scrupulously clean ; for 
it is through green vegetable food and fruits that the ova which lead to the 
growth of Cydicerd and Echinococd make their way into our bodies. Hence 
these immature forms of parasites are most common in cattle; while the 
mature tape-worms are mostly found in the carnivora. Man, being more or 
less omnivorous, is doubly hospitable, entertaining as a host both forms of 
unwelcome guests, the tapes and the cysts. 

In place of burying the excreta of animals known to be affected with Tceniw, 
all such excreta ought to be burned. If they are simply buried, or merely allowed 
to drop and lie on the ground, multitudes of minute embryos escape destruc- 
tion ; and may ultimately find their way into the human body. All entozoa 
(not preserved for adentifie investigation and experiment) should be thoroughly 
destroyed by fire when practicable, and under no circumstances should they be 
thrown aside as harmless refuse (Cobbold). 

Many of the immature entozoa pass their whole life as encysted parasites, 
and a few even acquire the jointed form, or become partially divided into seg- 
ments, while still within their closed cysts. A well-known example of this is 

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200 TOPICS RELATIVE TO PATHOLOGY. 

afforded by the C. faseiolaris, which inhabits cysts in the liver of the rat 
and mouse, and has been the means of leading Von Siebold and Dr. Henry 
Nelson (independently of each other's observations) to the discovery of the 
remarkable relation now proved to exist between the cystic or vesicular entozoa 
and the cestoidea or tape-worms. These observers found the cystic entozoa in 
the liver of the mouse and rat in every stage of development, from the sim- 
plest vesicular form of the true Oystieercus to that which (from the number of 
the joints and their external form) has all the appearance of a true tape- 
worm, and from which, in fact, it only differs in the absence of sexual organs 
within the segments. A careful comparison of the form of the head, its circle 
of booklets, the four oscula or suckers, and other parts in the Oystieercus of 
the rat or mouse, with those of the T. crassicoUis, which inhabits the intestine 
of the cat, has shown an exact resemblance between them. Dr. Allen Thom- 
son has repeated and confirmed these observations (Art. " Ovum," Oyelopcedia of 
Anatomy). The conclusion such observations lead to is now generally regarded 
as established — namely, that the cat receives its T. crassicoUis with the flesh 
of the mouse or rat which it may have eaten. 

Symptoms of the Presence of Tape-worm and Cystic Parasites. 

From what has been stated, it is obvious that these must be very variable, 
determined by the form of the parasite and the locality in which it exists. 
Almost every case has some special symptoms of its own, local, reflex, or 
general. 

In the alimentary canal the tape-worms occasion uneasiness, or pain in the 
abdomen, sometimes spasmodic, gnawing, or biting, but more frequently a dis- 
tressing feeling which cannot be described. Irritation at the mucous orifices 
(mouth, nose, and anus) are also characteristic accompaniments. The bowels 
may be constipated or relaxed ; the stools exceedingly dark or white ; the 
appetite sometimes lost and sometimes voracious ; sleep disturbed, and temper 
fretful ; and often, as a result of so many combined irritating causes, a remit- 
tent fever occurs, which has received the name of " worm fever." The mind 
is also often so much depressed as to amount to hypochondriasis. 

The symptoms of the existence of worms in the small intestine, such as 
Tcenia, are often exceedingly obscure, and simulate many other diseases ; so 
that, until a patient has passed a portion of the parasite worm, we are unable 
to predicate its existence with any certainty ; and at no time till we actually 
see the parasite can we determine its species. 

Prevention and Treatment of the Tape-worm and Vesicular Parasites. 

The preceding history points out very clearly the means to be adopted for 
the prevention of tape-worm and of cyst-infected meat. At the same time, 
it is probable that there may be other accidental means by which the larvfe 
of the tape-worm may be introduced; and it will be easily understood how 
this may more particularly happen in the cases of butchers, cooks, or others 
in the habit of handling affected meat. 

The instances in which the human body is affected with the Oystieercus or 
other cystic entozoa, though not rare, are by no means so frequent as those of 
tape-worm ; but they are much more serious in their effects, more obscure in 
their origin, and in the meantime, therefore, more difiicult to prevent. Scarcely 
any attention has yet been given to the source from which the various indi- 
viduals of the cystic entozoa infesting the human body may have derived their 
origin ; but the observations already referred to make it extremely probable 
that the explanation of their introduction is to be sought for in the same 
causes which have been shown to operate in the lower animals. Thus, it 

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MEDICINAL KEMEDIES FOR TAPE-WORM. 201 

appears to have been demonstrated that the Cwnunts of the sheep proceeds 
from the ova or first embryos of Tarda, and it is most probable that those are 
obtained from the excreta of the dog. The only mode, therefore, of removing 
this affection from a flock in which it may have become prevalent, and in 
which it is well known sometimes to cause very great losses, must be the care- 
ful separation of the dogs from the sheep for a certain titne; for such time, 
indeed, that the dog shall find no more Ctznuri in the offal of sheep which 
die of staggers, in eating which it receives the larvse of its Tcmia; and 
that the dog, being free from this Taenia, shall not furnish, by his excreta, 
the ova or embryos which, being taken accidentally with the pasture or water 
by the sheep, establish themselves in them as encysted Coenuri. Von Siebold 
states the important fact, that those flocks which are entirely without dogs, 
and are stall-fed, are never affected with the " sturdy." 

Medical Treatment. 

For the ejection of Taenia from the small intestines a great many remedies 
have been recommended ; but in the present day medical men very generally 
limit themselves to one or two methods, or to the action of a purgative. The 
celebrated Swiss remedy, purchased by one of the kings of France, was 
a purgative composed of twelve grains of calomel and twelve grains of scam- 
mony, followed shortly after by half an ounce to an ounce of the sulphate of 
magnesia. In many cases such a purgative has been efficient. 

The oleum terebinthince alone has been found to act well. Half an ounce 
to two ounces of this medicine makes the patient slightly tipsy, but is less 
likely to cause strangury than a smaller dose, and produces three or four 
motions. In one of these the worm is usually found, the animal having, it is 
supposed, a great antipathy to this substance, lets go its hold, and actively 
attempts to escape. This medicine may be repeated twice a week, if the first 
dose is not efficient. Three-fourths of the inhabitants of Cairo are said to be 
infested with Taenim, and the native remedy is twenty to thirty drops oi petro- 
leum — an agent not greatly dissimilar to turpentine. The Grenadine bark 
has acquired much reputation in this disease in the West Indies ; but it has 
not supported the hopes that have been entertained of it, at least in this 
country. 

Drs. Christison, Jenner, Gull, and others, have employed, with great suc- 
cess in tape-wopm, the ethereal oleo^esinous extract of the male shield fern 
(Lastraia Filix-mas) in doses of twenty to twenty-four grains — a remedy 
which by many is still believed to be the most efficacious. Dr. Gull's dose is 
one and a half to two drachms. The liquid extract of fern root is the offici- 
nal remedy of the British Pharmacopoeia. It is made from the rhizoma or 
rootstalk of the Aspidium or Nephrodimn Filix-mas, according to the formula : 
Fern root, in coarse powder, 1 part ; ether, 2 parts, or a sufficiency ; percolate 
and distil off the ether, and the liquid extract remains. The dose is nK 30 to 
nji 60, in milk, or with mucilage, and should be given on an empty stomach. 
Mr. Squire finds the extract of the unexpanded frond equally effective with 
that of the rhizome. The powder may be used alone in doses of one to three 
drachms. 

A remedy sometimes used in Germany is Chabert's handwurmol, or the 
" oleum Chaherti contra Tmniam." It is obtained by the distillation of twelve 
ounces of oil of turpentine mixed with four ounces of the oleum animate foeti- 
dum, which is the crude oil obtained from hartshorn and animal bones. 

A remedy of Abyssinian origin, called Kousso or Ousso, the flower of the 
Brayera antlielmintica, has recently been much recommended ; and has doubt- 
less been of great efficacy in some instances. It is administered in the form 
of powder, of which half an ounce is mixed with half a pint of warm water, 
and the infusion, with the sediment, is to be taken at two or three draughts, in 

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202 TOPICS RELATIVE TO PATHOLOGY. 

the morning, on an empty stomach. If the bowels fail to be moved, a brisk 
cathartic ought to be given in three or four hours. 

Another remedy of more recent recommendation is Kameela or Reroo, the 
Rottlera tinctoria of the natural order Etiphorhiacem, and sub-order Crotonece. 
It has been highly lauded by Dr. Gordon, Surgeon to the 10th Eegiment of 
Foot. He writes : 

" The success and rapidity of effect of the kameela in removing tape-worm 
in the cases of soldiers of the 10th Eegiment, to whom I administered it, were 
such that I did not consider it worth my while to keep notes of them after the 
first two or three ; nor, indeed, were the men to whom it was administered 
latterly taken into hospital, for they soon became aware of the wonderful effi- 
cacy of the remedy, asking of their own accord for a dose of it, after which 
they invariably parted with the worm in the course of a few hours, and then 
weiit on with their military duty as if nothing had happened; while, as 
I afterwards ascertained, considerable numbers did not think of 'troubling 
tlie doctor at all,' but, on suffering from the characteristic symptoms of the 
worm, applied for the kameela to the apothecary, and always with the same 
effect. 

"We prepared a spirituous tincture by adding Oj of alcohol to liv of the 
powder, and then filtering. We never succeeded in obtaining more than gvj 
in this way; and of this 3j in a little mint-water was generally found to be a 
sufficient dose, 5i.i being in some cases required, and perhaps in one or two, 
3iii; but I have never seen the remedy fail in removing the worm in a case 
where there were unequivocal sym])toms of its presence. 

" With kameela there is no unpleasant effect. It is not even necessary to 
take a dose of purging medicine as a preparative ; and bej'ond a trifling 
amount of nausea and griping in some instances, no unpleasant effects are 
experienced ; while by far the greater number of persons to whom it is admin- 
istered suffer no inconvenience whatever, beyond what they would from a dose 
of ordinary purging medicine" (Med. Times, 2d May, 1857). 

One to three drachms of the powder, suspended in gruel, mucilage, treacle, 
or syrup, will of itself expel the worm. Dr. Clymer suggests the following 
formula : 

Rottlerre, 3i ; Oleo Resinre Filicis, fjss. ; Mucilag. Acacia;, Syrupi Aurantii, 
aaf^ii; Misce et si/jha. One-half at bedtime, and the remainder the next 
evening — the patient fasting ten or twelve hours before. Should it not operate 
adequately, a dose of castor oil should be given. 

The duration or life of the parasite within the human intestine varies from 
a few months to thirty-five years ( Wauruch) ; and although it is considered 
by some absolutely necessary that the head of the animal should be expelled 
before the treatment can be considered successful, yet there are good grounds 
for believing that there is considei'able chance of destroying the parasite if 
large masses near the head are brought away. The worm is then likely to 
perish, the most actively gr(jwing and important portions being discharged. 
The head of the worm ought always to be sought for during treatment ; at 
the same time, not being easily found, the physician is not to be discouraged 
by not finding it. Out of 100 patients treated for Ta'tiia by Bremser, he only 
once found the head in the dejections ; yet all are said to have been cured. 
In the list given at p. 146, numliers 23, 24, 25, 2(5, 27, and 28 comprehend — 
Fluke-like Parasites. — They are of a flattened oval form, smooth, soft, and 
yellowish, or yellowish-brown, and not jointed nor segmented. Thej' are pro- 
vided with two discs ; one, situated at the pointed head extremity, forms a 
funnel-shaped depression leading to the oval orifice of a ramifying or bifurca- 
tinir alimentarv canal, which has no anal aperture. The other disc is situated 



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DEVELOPMENT OF DISTOMATA. 203 

on the abdomen, and terminates by a blind concavity. The opening of the 
sexual organs lies between the two discs. Male and female sexual organs are 
embodied in one and the same individual ; and (as in parasites generally) 
they pervade a very large portion of the body of the mature adult animal. 

A study of these parasites is of practical importance, chiefly in relation to 
their ova and early embryotic forms, which are now known to be developed 
in the open waters, or in minute water animals. It is therefore incumbent 
on us to be able to recognize them, and to know something of their natural 
history. 

The generation of some of these trematode parasites constitutes one of the 
most remarkable parts of the history of the process of reproduction among the 
Invertebrata. Two states or forms are known to exist — ^namely, a mature and 
an immature form — encysted and free. 

It is only in the mature form that the generative organs are found. Such 
mature Distomata have their habitat in the biliary passages, especially of the 
Buminantia, as well as in man. Among sheep the disease induced by Trema- 
todes often commits great devastation, and is commonly known by the name 
of " the rot." These fluke-like parasites are found in all grazing cattle, also 
in the horse, ass, hare, rabbit, squirrel, antelope, deer, beaver, and man. 

These fluke-like parasites are chiefly injurious to man, indirectly, by their 
prevalence in the lower animals, causing meat to be unfit for food ; although 
such meat is largely eaten by poor people. 

The odor of sheep with rot is peculiarly offensive ; the flesh is wasted, flabby, 
and watery ; and hundreds of thousands of sheep die every year, especially in 
marshy districts, from the efiects of the liver fluke. 

It is only very recently that the facts connected with the natural history 
of these parasites have been ascertained, and their general result may be' 
stated as follows: The fully grown and 
sexually mature Tr&matodes (as exemplified fig. 36. 

in the Distomata') are parasites of the higher 
Vertebrata, and are oviparous. The egg is 
yljjth of an inch long, and ^yxr^h of an inch 
wide. 

When the egg of the Distoma opens (by 
the springing open of a sort of hood, which 
gives it the operculated appearance at one 
end), it gives vent to an embryo which moves 
rapidly by means of cilia, as is the case with 
many infusorise, and especially of the Opo- Egg of Distoma. Opaiina. 

Una, now regarded by Schultze, ■ Agassiz, 

and Stein as the earliest embryonic form of a Distoma. The discovery was 
made by Agassiz that a genuine . Opaiina (Fig. 36, 6) was hatched from the 
egg (Fig. 36, a) of the Distoma. As such, they are found in sewage water' 
(see A. H. Hassall's Reports on the Water of London) ; also in the fseces of 
animals infested with liver flukes, their ova passing out with the bile. The 
eggs continue to develop in water, and each egg finally produces an embryo- 
which swims freely by cilia. They die in pure water, as many vermicular 
animals do who would be more fortunate in water which is dirty, full of 
organic impurities, and abounding in food fitted for them. 

From each of these ova is formed, an embryo, in which no resemblance to 
the parent Trematode is to be recognized; but presenting the simple structure 
of a ciliated animalcule, like a polygastric infusorian known as the Opaiina. 
This embryo is not itself converted by any direct process of development or 
metamorphosis into a perfect Distoma, but has a progeny gradually formed from 
germ-cells within it, and consisting sometimes of one, but more frequently 
of a number of bodies which, when they arrive at maturity, present each one 
an exteriial form and internal structure and locomotive powers entitling them 

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204 TOPICS RELATIVE TO PATHOLOGY. 

to be considered as independent animals. Nor are these directly converted 
into Distomata; a new progeny of animals is formed as before, nearly similar 
to those producing them, and equally differing from the complete Distomata. 
Each individual of this new progeny, as it increases in size, has formed within 
it, by development from germ-cells, the third progeny of the series and last of 
the cycle. These are different from their immediate parents, and in their 
internal organization soon manifest the type of the true Trematoda. They are 
endowed for a time with very active locomotive powers, to which a long 
caudal appendage contributes. Their progenitors have been confined in the 
parasitic condition; but these are in general freed from confinement, and 
move about with great vivacity for a time in the water surrounding the ani- 
•mals which their progenitors infested. 

In this state they have been long known as Cercarice, having the appear- 
ance of minute worms with tails, and were classed by Mueller, the Danish 
zoologist, with the Infusories. Regarding the history of the development of 
these animals, information is only fragmentary ; yet so different periods have 
been observed in the development of different species of these Trematodes, 
that by analogy a tolerably connected history has been obtained of the whole 
process. 

These Cercarice in water are observed to be exceedingly lively and active, 
both as to body and tail ; and after moving about free in the water, they begin 
to go through a metamorphosis of a most extraordinary kind. They either be- 
come inclosed like a chrysalis in a pupa case, or penetrating the bodies of soft 
animals, or embryos of the animals, inhabiting the water — e. g., snails, fish, 
larvae of insects, and the like — they become encysted within these bodies. They 
thus become parasites, for example, in the mussel family {Mytilus edulis) ; in the 
ovisacs of the Gammarus, or sandhopper (a small crustacean abounding on 
our sandy shores, and which may be seen leaping up in myriads from the 
"beach) ; also in snails, frogs, newts, and the like. 

In the cavities of these animals it lives as a ciliated animal, and multiplies 
by division of its body. 

The next change in these parasites is that the cilia vanish. They fix them- 
selves, and become by and by oval motionless bodies (Steensteup, Peichaed, 
p. 270), which continue to grow, and in which a germinal mass becomes visi- 
ble, of an elongated form, and out of which the first form of a Cercaria arises. 
It is a single-mouthed parasite, and is known as the Monostoma mutabile, in- 
habiting the ibtestinal cavity of water birds. 

In the interior of this parasite arises another embryo, which becomes free, and 
passes out of the bird into the water again ; and being yet furnished with cilia, 
it makes its way especially into the aquatic larvse of insects — e. g., ephemera, 
caddice worms (Phryganidm), the dragon-fly {Libellulidce) ; and into the soft 
embryos of fishes like those of the cod kind ; in snails, mussels, and such kinds 
of water animals, all used as bait and food for fishes. 

Out of this ciliated embryo a germ pouch, as it has been called, makes its 
way ; and from this germ pouch the Cercarice broods are developed. In the 
eyes of the fishes, they inhabit the aqueous humors. Thus it seems probable 
that Distomata enter the human intestinal canal as Cercarice, and pass thence 
into the biliary passages (Feerichs) ; and according to the observations of 
Giesker and Frey, they may also penetrate directly into the skin, and undergo 
development in the subcutaneous cellular tissue. Two Distoma were found 
in the interior of a tumor on the sole of a woman's foot ; and in all probability, 
as Frerichs remarks, the Cercarice had entered the sole of this woman's foot 
while she was bathing in stagnant portions of the lake at Zurich. In another 
instance it was found in a cyst behind the ear of a sailor, aged thirty-nine, 
and in an abscess in the head of a boy twenty-five months old (Murchison, in 
Translation of Frerichs's Diseases of the Liver, vol. ii, p. 488). The eating of 
uncooked fish, whelks, shell-fish, and uncooked garden snails, are all obvious 

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LESIONS FROM BILHARZIA H^MATOBIA. 205 

modes in which the Cercarice of the Trematoda may find an entrance into the 
bodies of man and other animals. 

Nine species of fluke-like parasites have been found in man. They have 
been named as follows (the numbers correspond to the list at p. 146) : 

23. Fasciola hepatica, in its full-grown condition, measures from eight to 
fourteen lines in length, and from three to six lines in breadth. 

24. Distoma crassum. — In 1843 Mr. Busk found fourteen of these Distoma 
in the duodenum of a Lascar who died on board the "Dreadnought" hospital 
ship in the Thames. They are thicker and larger than those of the sheep, 
varying from one and a half to nearly three inches in length. 

25. Distoma lanceolatum. — Very few (only three) instances are known of 
its occurrence in man. The eggs are g-Joth of an inch long, and -j^th wide. 

26. Distoma ophthalmobium. — It is recorded that four specimens have 
been found in the eye of a child five months old, born with lenticular cataract. 
No one of them exceeded half a line in length ; and they were situated between 
the lens and its capsule, where they could be recognized as so many dark 
spots on the surface of the lens (Cobbold). 

27. Distoma hcterophyes was found by Dr. Bilharz, of Cairo, in 1851, in 
the small intestine of a boy ; and on a second occasion he collected several 
hundred specimens under very similar circumstances. The parts infested 
displayed a multitude of reddish points, due to the presence of dark-colored 
ova in the interior of the worms. The length of the largest specimens did 
not exceed three-fourths of a line (Siebold, Cobbold). 

28. Bilharzia hsematobia is so named by Dr. Cobbold in honor of its dis- 
tinguished discoverer. It is, however, a bisexual parasite. The body of the 
male is thread-shaped, round, white, and flattened anteriorly. The oral sucker 
is triangular; the abdominal sucker at the end of the trunk is circular. Below 
this, at the curved margin of the abdomen, a furrowed canal exists for the 
reception of the female. This canal is peculiar and distinctive, and renders 
this Distoma generically distinct from the Distomata already noticed. The 
genital pore lies between the abdominal sucker and the commencement of the 
canalis gynmcophorus. The female is very thin and delicate ; its tail is not 
provided with any canal. The suckers resemble those in the male ; but the 
genital pore and the abdominial sucker are in contact. The length of the 
animal amounts to three or four lines, and the male is broader than the 
female (Feeeichs, Muechison, Cobbold). Another name has therefore 
been given to it — namely, the GyncBCophorus hmmatohius (Diesing) ; but by 
whichever name it is known, it is of remarkable interest, not only from its 
peculiar anatomical structure, but from its great prevalence on the borders 
of the Nile, and from the grave and characteristic symptoms and appearances 
to which it gives rise. According to Griesinger, it is met with in Egypt 177 
times in 363 necropsies — i. e., equal to 33 per cent. 

The first specimens were discovered by Bilharz, of Cairo, in the portal 
vein and its branches, and likewise in the walls of the urinary bladder. It 
has been since observed by Griesinger, Keinhart, and Lautner in the veins of 
the mesentery, urinary bladder, ureters, and pelvis of the kidney, giving rise 
to a formidable and very prevalent disease. In the larger vessels, such as 
those of the liver, this Distoma gives rise to no derangements equal to those 
which result when it exists in the lining membrane of the urinary passages 
and the intestinal canal. There it induces hemorrhage and inflammation. 
In the intestine they are often associated with appearances resembling those 
of dysentery, with congestion, extravasation of blood, deposit upon and 
beneath the mucous membrane, fungoid excrescences, and croupy exudations 
that occupy ulcerated patches of the bowel. In many of these cases the eggs 
of the creature may be found wedged in long rows within the intestinal 
vessels, or in and beneath exudations on the free surface of the mucous 
membrane. Hence it has been suspected whether the dysentery endemic to- 

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206 TOPICS RELATIVE TO PATHOLOGY. 

Egypt may not have to the presence of these Distoma the same relation as 
the itch has to the Aearus. Such a conclusion receives a strong confirmation 
when we turn to the lesions produced in the urinary apparatus. Here the 
mucous membrane appears swollen in places which are covered with a soft, 
sandy, rotten mass, that is firmly fixed to the subjacent tissue. The micro- 
scope shows this mass to consist of the full and empty shells of the parasitic 
ova, imbedded in a mixture of blood, exudation, modified epithelium, and 
crystals of uric acid. The thickening of the submucous tissue often produces 
stricture of the ureter, which is followed by retention of urine and all its dan- 
gerous consequences,— degeneration of the kidneys, pyelitis, dilatation of the 
pelvis, or atrophy of the renal substance ; or the masses themselves become 
the nuclei of calculous deposits, and thus aid in the chlorotic exhaustion 
these creatures produce in the person they inhabit, by the consumption and 
loss of blood they imply. Lastly, it seems not unlikely that the dislodgment 
of clots into the general circulation sometimes brings about pneumonia, in 
the way described " by Virchow, and illustrated by the clinical researches of 
Kirkes (Brit, and For. Med.-Chir. Review, 1. c, p. 125). Professor Virchow 
was good enough to show me a specimen, in his museum, of lesions in the 
bladder efiected by the existence of this Didoma. The entire trunk of the 
portal vein is sometimes filled with this parasite, while their ova are found in 
the tissue of the liver ; but the symptoms to which the D. hwmatohium gives 
rise are more referable to the urinary organs than to the liver. The urine is 
bloody, and sometimes contains the ova of the Distoma ; and a state of pro- 
found cachexia supervenes (Feerichs, Cobbold, MoQtriN-TANDON). Dr. 
John Harley, of King's College, London, has recently directed the attention 
of the profession in this country to the remarkable prevalence of hxzmatv/ria 
at the Cape of Good Hope — a condition which he found associated with the 
fertile ova of this entozoon passed in the urine. After micturition, a little 
blood, never exceeding a teaspoonful, or some dark coagula, like " veins," 
appear with the last half-ounce of urine. The urine itself is never bloody. 

Sometimes the blood-coagula will block up 
Fi6. 37. the urethra, and cause obstruction for a few 

minutes. These are all the symptoms which 
appear in connection with the urinary appa- 
ratus ; and numbers of people of both sexes 
are affected in precisely the same way in 
certain parts of the Cape — as endemic hsema- 
turia — especially at Uitenhage and Port 
Elizabeth. In various samples of urine sent 
to him by a person suffering from this affec- 
tion, he invariably detected the ova of this 
entozoon. Of these he was kind enough to 
give me specimens, and a copy of the wood- 
(\.)o^nra«t jDistomahmmatobmmiTom cut (Pig. 37). The eggs measure 3 -J^th of 
hsematuria of the Cape of Good Hope rDE. an mch long, and -^gth of an inch broad. 
from'ovunfSiKuie; (3.) Bttbryo attached He was successful in observing the perfect 
io the ovum capsule. ciliated embryo after its escape from the 

Shell; Fig. 37 (2) and (3). 
Dr. Cobbold has discovered the same Distoma in the portal system of an 
African monkey. 

29. The Tetrastoma renale, as its name implies, infests the tubes of the 
Tcidney, and was discovered in 1833 by Lucarelli and Delia Chiaje. It 
attains a length of five lines, has an oval, flattened body, and is furnished 
with four suckers disposed in a quadrate manner at the "caudal extremity. 
The reproductive organs are situated near the mouth. 

30. Hexathyridium venarum has been found in venous blood, and from the 
sputa of persons suffering from haemoptysis (Teeutlee, Chiaje, Follina). 

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DESCRIPTION OF ACCIDENTAL PARASITES. 207 

It attains a length of three lines, is cylindrico-lauceolate, with six suckers 
biserially disposed on the under side of the so-called head (Cobbold). 

.Sl.Hexathyriduiin pinguicola was once found in a diseased ovarium. The 
parasite attains a length of eight lines (Teeutlee, Owen). 

Symptoms. — The symptoms to which Didom/dn give rise in the liuraan sub- 
ject must of course vary with the site of the parasite ; but nothing definite is 
known regarding them, except in the cases of hmnaturia and dysentery, already 
noticed. In sheep their presence occasions dilatation and catarrli of the bil- 
iary passages, accompanied by atrophy of the hepatic tissue. Jaundice rarely 
showsitself, and then only lasts a short time; but ultimately a condition of 
ansemia is developed, under which numbers of sheep die. The disease is known 
as " the rot " among sheep ; and it prevails to a considerable extent among 
flocks feeding on marshy and wet land near the shores of rivers. 

In the human liver bodies have been found like the ova of entozoa, so fre- 
quently met with in the liver of rabbits (Gublee, cpu^ted by Freeichs). 



CLASS C. ACCIDENTAL PARASITES. 

Definition — Internal parasites, having the habits but not referable to the class 
of entozoa. 

32. ^ Pentastoma denticulatum has been conclusively shown by Leuckart's 
experiments to be the larvw or sexually immature condition of Pentastoma 
tcenoides, and is found in the liver and small intestines. 

33. Pentastoma constrictum — The author had two portions of lung and 
three portions of liver, each containing an unusual parasite, sent to him" from 
Jamaica, in August, 1865, for the Museum of the Army Medical Department 
at Netley. Staff Assistant-Surgeon Edward Barrett "Kearney, Esq., is the 
donor of the specimens ; and from his history of the patient's fatal illness, the 
following account has been drawn up : 

On the 11th of January, 1865, private Isaac Newton was admitted into the 
hospital of the 5th West India Regiment, at Up Park Camp, Jamaica, for an 
attack of tonsillitis. He was an African, enlisted aljout eight months pre- 
viously from the slave depot at Rupert's Valley, St. Helena, where all slaves 
captured in slave-ships are kept until disposed of He appeared to be about 
twenty-one years of age, and of a thin spare habit of body. 

On admission the tonsils were inflamed and enlarged, but not ulcerated ; 
and there were aphthous ulcers about the tongue. He suffered from headache 
and pain across the back. 

On the morning of the l-lrtli he complained of great pain in the abdomen, 
which became tympanitic. His tongue was clean, but vividly red at the edges 
and tip, and it felt dry to the touch. The skin was very hot and dry and 
harsh, and his pulse 100. The pulse continued to increase in quickness ; 
sordes soon began to appear about the mouth and teeth, and the tongue 
became furred and cracked. Large moist crepitation was heard over the 
whole surface of both lungs. He became low, and disinclined to be spoken 
to, and by six o'clock in the evening his mind appeared to be confused. He 
passed his urine and his stools involuntarily in bed. 

On the 15th there was no improvement in his condition, and at ten o'clock 
at night he appeared to be in much the same state as before, and the bowels 
were confined. 

On the 16th he appeared livelier in the morning, the skin cooler, but still 
dry. ^ He was thirsty, and sordes were still about the lips and teeth. The con- 
junctiva3 of both eyes were stained of a vivid yellow color. 

About nine in the evening he became suddenly worse. His pulse became 
very weak and almost indistinct, the skin cold, the countenance sunken, and 



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208 TOPICS RELATIVE TO PATHOLOGY. 

covered with a copious perspiration. He appeared to be sinking, and he died 
at half-past ten that night. 

Post-mortem Examination Fourteen Hours after Death.— The general appear- 
ance of the body was that of emaciation, with yellowness of the conjunctiva. 
Thorax. — The subcutaneous areolar tissue over the chest and abdomen was 
of a deep yellow color. The pericardium contained about four ounces of deep 
amber-colored fluid. 

The Heart was large and pale, but its substance was otherwise normal, and 
its valves healthy. The Lungs were both highly congested ; and when cut 
into, a bloody frothy fluid exuded in quantity. The substance of both was 
very friable and yellowish in color. " On the anterior surface of the right 
lung, and near the edge of its lower lobe, one or two yellow species appeared. 
They were about the size of a spangle, and when end 
Fig. 38. into, worms were seen regularly encysted in its sub- 

stance." On the posterior surface of both lungs 
- there were numerous adhesions of long standing. 

Abdomen. — The Liver was very large, extending 
into the left hypochondrium. "Its surface was 
dotted over, both posteriorly and anteriorly, with about 
twenty or thirty yellow species similar to those seen in 
the lung." The hepatic substance appeared paler 
and rather more soft than natural. 

Stomach. — It was distended with air and fluid, 
, containing about a pint and a half of dark-green-colored fluid. The mucous 
membrane was congested in patches, in the stomach, and along the whole 
tract of the intestines. There was no ulceration; and no appearance of 
Tcenice, either continuous or in proglottides, could be discovered. Other organs 
were healthy. 

Description of the Parasite and the Lesions it produced. — Fig. 38 repre- 
sents a small portion of the lung, with the little worm seen at a curled up in 
its cyst. The pleura has been removed, so as to expose the "rings," "mark- 
ings," or " constrictions," which are characteristic of the body of this para- 
site. The pleura was opaque and considerably thickened, probably from the 
irritation of the parasite. 

The appearance of the parasite on the surface of the liver was exactly 
similar to that in the lung, and therefore it is unnecessary to give another 
drawing ; and wherever the serous covering of the organ was sufficiently 
transparent, the constrictions of the parasite could be seen distinctly shining 
through. 

Fig. 39 represents two specimens of the parasite removed from their cysts. 
They are of the natural size, and one of them, a, is much shorter than the 
other, the constrictions being closer together : a measures five lines 
in length, b measures about eight lines. In diameter they are 
about one line. About twenty to twenty-three rings or constric- 
. tions can be counted on the elongated body, at tolerably regular 
intervals, and somewhat spirally arranged. 

Fig. 40 represents the two specimens of the parasite slightly 
magnified (about three diameters) : a is the shorter ; b and c are 
the posterior and anterior aspects of the longer of the two worms. 
The head end appears compressed, so as to be flat and square- 
shaped at the end. It is seen to be marked with five spots on the anterior 
aspect, as shown at c. The posterior aspect of the flattened head, as shown at 
b, is comparatively smooth. The elongated body is rounded, and the caudal 
end terminates in a blunt-pointed cone. The constrictions appear like folds 
of the outer covering of the worm, each fold overlapping the one which follows, 
from the head to the tail. The body of the parasite is rounded, and not flat, 
as the tape-worms or cysticerci. 

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209 



Fig. 40. 




f^ 



f 






Fig. 41. 



Fig. 41 represents the anterior aspect of the flattened head end (cephalo- 
thorax) of the parasite. It is so highly magnified as to show the nature of 
the five spots or marks shown in Fig. 40. 

The dotted lines from a and l point to two 
pairs of hooks or claws — one pair on each side of 
a pit or mouth, c. The points of the claws, in- 
dicated by a, are seen nearly in profile ; those at 
h are directed more towards the observer. These 
claws appear to be implanted in socket-like hol- 
lows or depressions, surrounded by much loose 
integument. These socket-like hollows appear 
to be elevated on the summit of the mass of tissue 
which lies underneath the folds of integuments 
surrounding the base of the hooks. These parts 
are regarded as the feet of the parasite, and the 
hooks are the foot claws. 

The pit or mouth (indicated by the dotted line 
to c) is of an oval shape, the long axis of the oval ', ', ^ ' 

lying in the direction of the length of the worm. 
The lip or outer margin of the pit is marked by 

a well-defined thin line. There are no spines nor hooks on the integument of 
the elongated body. 

From the description and the drawings here given, it will be seen that the 
parasite corresponds in its specific char- 
acters with the larval condition of the 
" Pentastoma constrictuin." It belongs to 
the family acanthotheca of Diesing, and 
has no structural connection with the 
true helminth parasites found in the 
bodies of man and other animals. 

The parasite now described, when 
compared with the descriptions of penta- 
stomata given by Frerichs, Cobbold, and 
other observers, demonstrates clearly 
that at least two species of petastomata 
infest the human body ; the Pentastoma ^ 
constrietwn being by far the larger, the 
more dangerous, ■ and fortunately the 
more rare, of the two species. It is also 
still more satisfactory to know that, as 
a human parasite, neither of the two 
species has ever been detected in this 
country ; and according to the researches 
of Dr. Cobbold, it is only in the encysted 
or larval conditions that the pentastomata 
are met with in the human body. As 
an embryo it becomes encysted. The 
cyst is composed of condensed connective 
tissue, and is lined by layers of loose 
flakes, which are evidently the remains 
of repeated castings of the skin of the 
parasite; and during the intervals of 
these successive moultings the worm 
makes considerable growth, so as to 
reach the size in which it is finally found. 
In this pupa or larval condition it occurs 
in the solid organs of the abdominal and thoracic cavities of man in certain 

VOL. I. 14 

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210 TOPICS RELATIVE TO PATHOLOGY. 

geographical districts in Europe, Egypt, and the West Coast of Africa, and 
much more frequently in various herbivorous animals, such as the sheep, deer, 
antelope, peccary, porcupine, Guinea pig, hare, rat, and domestic cat (Cob- 
bold). In all these animals, and in man, the larva usually occupy cysts 
immediately underneath the serous covering of the liver and the lungs ; and 
Dr. Cobbold mentions that he has occasionally found the Pentastoma denticu- 
latum free in the cavities of the abdomen and pleura of animals. 

Our knowledge of the natural history of these parasites is mainly derived 
from descriptions of the Pentastoma denticulatum, the larval or sexually im- 
mature condition of the Pentastoma tcenoides of Rudolphi. We are told by 
Frerichs (Cliiiioal Treatise on Diseases of the Liver, vol. ii, p. 276) that Pruner 
was the first observer who pointed out, in 1847, the existence of the penta-doma 
as a parasite in the human subject. On two occasions he found i^entaatoma in 
the liver of negroes at Cairo. He does not seem, however, to have determined 
accurately the nature of the parasite he observed ; and he also subsequently 
found two specimens of the worm preserved in the Pathological Museum at 
Bologna, which had been removed from the human liver (Cobbold). Bilharz 
has since repeatedly detected in the livers of negroes at Cairo the parasite 
discovered by Pruner in 1847. Bilharz and Von Siebold made this parasite 
the subject of careful study ; and they recognized in it a variety of pentastoiim 
quite different from that which prevailed in some parts of Germany. They 
gave this new variety the name of Pentastoma comtrictum — the parasite which 
has proved fatal in the case whose history Dr. Kearney has sent to me from 
Jamaica. It is the form of jyentastoma endemic in Egypt, and hitherto it has 
only been found in the African negro. It differs from the Pentastoma dentic- 
ulatum (the larval form of the Pentastoma tcenoides), "in not being furnished 
with any integumentary armature of spines, and in its being a much larger 
worm" (Cobbold, p. 402). The Pentastoma eonstridum seems to be fi'om 
eight to twelve times larger than the Pentastoma denticulatum, and therefore 
is all the more dangerous from its actual size (nearly an inch long) ; and 
when it occurs in great numbers, as in the present instance, it cannot fail to 
prove an extremely irritant " foreign body," when it escapes into a serous 
cavity like the pleura or peritoneum — a mode in which it seems to cause 
death. The latter parasite (P. denticulatum) has been full)' described by 
Frerichs, and figured by him in his Atlas, plate xi. Fig. 9, as endemic in Ger- 
many in the human liver — in which organ it is considered to be far more 
common than the echinococcus.* Frerichs, however, regards the pentastoma 
endemic in Germany as devoid of clinical importance, because it does not 
give rise to any functional derangement. Not so, however, is such the inno- 
cent history of the Pentastoma constrictiim as it affects the negro ; and after 
the history of the case now given, the clinical importance of this parasite can- 
not be disregarded. 

As to the mode in which it tends to cause death, the evidence in this case, 
from symptoms and post-mortem examination, seems to poiut to pneumonia 
and sudden collapse from peritonitis. The author is able also to verify this 
point in the pathology of this parasitic disease still more clearly from a prepa- 

* " In Germany," says TrericVis, " the pentastoma was first found in the human liver 
by Zenker in 1854: it occurs, however, not only in this gland, but also in the kidneys, 
and in the submucous tissue of the small intestine (Wag.ser). The parasite is by no 
means rare with us. Zenker, at Dresden, succeeded in finding it 9 times in 168 autop- 
sies (or, according to Kuchenmeister, 30 times in 200 autopsies). Hesehl, in Vienna, 
met with it 5 times out of 20 autopsies; Wagner, at Leipsic, once in 10. According 
to Virchow, it is more common in Berlin than in Central Germany. During six months 
at Breslau, I (Frerichs) met with it in 5 out of 47 dead bodies. As a rule there is only 
one present ; in rare cases there are only two or three. It presents the form of a some- 
what prominent nodule, from 1 to 1 J lines in length, which is formed by a firm fibrous 
capsule, easily detached from the surrounding parts. The animal lies coiled up in the 
interior of this capsule " (On Diseases of the Liver, vol. ii, p. 27G). 

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PBNTASTOMA IN THE HUMAN LIVER. 



211 



Fig. 42. 



ration which has been in the Museum of the Army Medical Department since 
1854, but the nature of which he could not understand till the history of the 
case now published was so thoughtfully furnished by Dr. Kearney, together 
with the specimens of the parasite in situ which he sent. 

The preparation in the Museum (hitherto a puzzle to all who have examined 
it) consists of four pieces of liver (Fig. 42, a, b, c, d), and appears in the Cata- 
logue with the following description : 

" Portions of liver, containing numerous small cysts (evidently some jointed 
entozoon), taken from Private George Sutton, 1st West India Regiment, who 
died at Bathurst, Gambia ; and for the history of the case reference is made to 
the annual report of sick and wounded from that station, dated March, 1854." 

The author is now able to identify this preparation 
as an example of lesions produced by the PentaMoma 
eonstrictum. At a, in the cyst where the larva has been, 
there is contained the debris of integumentary exuvise ; 
at h, the head end of the parasite is seen peering out of 
an ulcerated opening in the serous covering of the liver. 
The edge of the opening is rounded and indurated, as if 
a good deal of local irritation had been maintained at 
the part previous to penetration of the serous covering. 
At c, the ring-like constrictions of the parasite are seen 
shining through a very thin portion of serous membrane ; 
and the portion of liver at d represents an empty cavity 
— whence one of these larvae has passed out, probably 
into the peritoneum. The cicatricial-like contraction 
and puckering of tissue in the vicinity shows that con- 
siderable irritation has existed previous to the exit of 
the parasite. 

We have no information as to how the Pentastoma 
eonstrictum finds its way into the human body as an em- 
bryo and subsequent larva. Although in this instance 
the negro was stationed in Jamaica, it is most probable 
that he had the germs of these parasites within him when 
he left his native shores in some part of Africa ; and 
that this parasite is neither endemic in St. Helena nor 
in Jamaica. Reasoning from what is known regarding 
the propagation and development of the Pentastoma 
denticulatum, it is probable that the ova with the contained embryos are in- 
troduced into the human stomach along with uncooked vegetable food (fruits 
or salads), in regions where the mature animals are endemic. From the 
stomach the embryos, escaping from the ova, bore their way, and find a rest- 
ing-place in the liver or other solid viscus, exactly like the embryo of the 
taenia. In solid organs (like the lungs and liver) they become encysted, and 
undergo the pupal transformation so well described by Leuckart and Cobbold 
in the case of the pentastoma endemic in Germany. 

The drawings which illustrate this paper were made by Staff Assistant Sur- 
geon Dr. Humphrey C. Gillespie, from the preparations which are now in the 
Pathological Museum of the Army Medical Department at Netley. 

34. (Estrns hominis. — Various insects and their larvae are apt to infest 
man, such as "bots," the CEstrus bovis, and the larva of a species of musca 
in Africa (Kirk). Five cases of the CEstrus hominis are recorded in man. 
They are the larva} of the oestridce, the bot-flies, breeze-flies, or gad-flies. The 
females deposit their eggs on the bodies of different herbivorous animals, and 
each species of fly keeps to its own particular species of animal. 

35. Anthomyia canicularis are known as exciting causes of boils by their 
larvae; and under this head, it may be convenient to notice that my friend Dr. 
Albert A. Gore, Staff" Assistant Surgeon on the West Coast of Africa, has 




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212 



TOPICS RELATIVE TO PATHOLOGY. 



kindly favored me with the following 
the exciting cause of Bulama boil: 



account of a larva or grub which 



Fig. 43. 

Natural size of larva or grub, 
the exciting cause of Bularaa 
boil. 

Fig. 44. 



"This small larva or grub is of a white color, a line or two in length, and is 
the exciting cause of a boil occasionally seen in the Island of Bulama and its 
neighborhood (Fig. 43). When magnified under a 
low power (Fig. 44), it appears to be divided into a 
series of joints, and covered with minute bulbous hairs. 
On the anterior division are placed four or five red 
spots (b), and from either side jjroject two hollow suc- 
tion-tubes (a, a). The posterior extremity seems to be 
terminated by a blunt hook. In applying a higher 
power the bulbous hairs turn out to be a numlser of 
beautiful black booklets (Fig. 45), which have a very 
pretty appearance on the white surface. A faint out- 
line of a central cavity can be discerned. The hook- 
lets are directed anteriorly. 

"Symptoms, Treatment, &c. — Attention is first at- 
tracted to the part by feeling an extreme itchy sensa- 
tion. On examination, a small red pimple is seen. 
After a while a small serous discharge oozes from its 
centre, which sometimes seems to pulsate. If allowed 
to progress, it becomes a regular inflamed boil, very 
„„ „..,.„ painful, and often causing an erysipelatous blush, with 
l>r. (a, CL) iiui- inflammation in the neighboring lymphatics, and ten- 
io^otiierdo[s'on dcrness of the glands to which they run. On the evac- 
uation of the small abscess in the boil these sj'mptoms 
gradually disappear, but a persistent red mark remains 
at the original seat of the disease. The treatment con- 
sists in poulticing until the little animal appears, when 
it can be withdrawn. If allowed to suppurate, it must 
be treated in the usual way of a boil under similar cir- 
cumstances. The natives put in a mixture of salt and palm oil, which takes 
out the little grub. 

"Etiology and Pathology.— This little worm cannot be the chigoe or Pukx 
penetrans of the West Indies, although it may result from the ova deposited 
by some similar aphanipterous insect. The (Mgoe chiefly attacks the toes or 
intervals between them, and causes a series of painful ulcers. It is also of a 
black color. This small grub is white, causes a boil or two in any portion of 
the body, most commonly in the tliigh, arm, or abdomen; it "is sporadic, 
although endemic. They have one symptom in common — viz., the extreme 
itchiness. But this is complained of in nearly every case of disease resulting 
from insect or other living organisms." 




The same grub magnified 
by a low power, 
low suction-tubes 
red .spots. The 
the body are hooklets, 

Fic. 45. 

^ f 
Two of the hooklets highly 
magnified. These drawings 
were furnished by Dr. Gore. 



II. ECTOZOA. 

Definition. — Animak living vpon the d-in and hair. 

Pathology.— These parasites are of three kinds— namely, lice, mites, ticks 
or spiders, and fleas. 

1. The first kind belong to the fiimily of "lice" (Ped^iculidcv), of the class 
Insecta, amongst the annidose or artictdated animals. They belong to the 
order Anoj>lura, all of which are parasites and destitute of wings. They un- 
dergo no regular metamorphosis, as most other insects do ; but in their growth 
to maturity they shed their skin a certain number of times, which may to 
some extent explain the irritation and forms of lesion to which they give rise. 
Almost all animals- man, quadrupeds, birds, aud reptiles— are liable to be 
infested with these parasites ; and were it not for our instinctive feelings of 



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THE INGUINAL AND HEAD LOUSE. 213 

disgust witli regard to them, as opposed to our notions of cleanliness and pro- 
priety, the study of their forms and habits is of considerable interest to the 
pathologist. Upwards of 500 species of lice have been described — universally 
diffused over the animal kingdom in different climates of the world. Their 
superabundance upon the persons of the human race is associated with some 
severe lesions of the skin ; and authentic cases are related of death from lousi- 
ness. A technical name has been given to this condition, namely : 

Phthiriasis. — Lousiness is a morbid state in which lice develop themselves 
to such an extent that a pruriginous eruption is produced (Prurigo jjedieii- 
laria). The skins of persons liable to constitutional skin diseases in which 
watery or secreting eruptions (such as eczema) prevail, are those most favor- 
able for the development of lice. 

Five forms of lice infest the skin of man. One variety is met with on the 
hair of the head — the Pediculus capitis; a second variety infests the other 
hairy parts of the body, but especially the pubis ; and hence its name — Pe- 
diculus pubis; the third form lives on the general trunk of the body — ^the 
Pediculus corporis; a fourth is the Pediculus palpebrarum; and a fifth the 
Pediculus tabescentium. 

The first four species, although they live in close proximity to one another, 
yet strictly limit themselves to the regions mentioned. In a clinical point of 
view the P. corporis is the most important. 

2. The second kind of animals associated with diseases of the skin belong 
to the family of "mites" or "ticks" (Acaridce), of the class Arachnida, 
amongst the annulose or articulated animals. Some of these are free, others are 
parasitic, and vary somewhat in their structure accordingly. Those which 
live a parasitic life have the mouth in the form of a sucker. Such are the 
"ticks," which fasten upon dogs, cows, sheep, horses, and other animals. They 
bury their' suckers so deep in the skin that it is impossible to detach them 
without tearing the skin to which they fix themselves ; and they multiply so 
rapidly that oxen and horses attacked by them have been known to die of 
mere exhaustion. The harvest ticks (Leptidce), one species of which, the 
Ijcptus autumiialis, well known as the harvest bug, is common in autumn in 
grass and herbage, from which it gets on the body of man, and, though ex- 
ceedingly small, produces extreme irritation of the skin. One only of these 
parasitic Acari has been found to live entirely in the skin of man — the Sarcoptes 
gain vel Acarus scabiei — producing the disease called the itch. 

(3.) The third kind includes the common flea, Pulex irritans, and the 
Pulex penetrans or chigoe. 

36. Phthirius inguinalis, or the Crab Louse (Fig. 46), has a shield-shape, 
and a much broader body in proportion to its size than any other form of 
louse; and there does not appear to be any distinct ^^^ ^^ 
separation between its thorax and abdomen. It has 
been met with on all the hairy parts of the body 
except the head, but more especially on the hair of 
the pubis. It does not run about like other lice, 
but grasps the stems of the hairs with its fore legs, 
and adheres so firmly that it is difficult to remove 
it without pulling out the hair. The nits or egg 
capsules are attached to the hairs in the same way I i i i i i i i i i I 

as on the head. Pruriginous or eczematous erup- loothsofan inch x lo diameters. 
tions, which mav become pustular, are the results The Crab Louse (after an- 

/. .1 '. . , •' ^ A \ DERSON). 

01 their existence (Andeeson).. 

37. Pediculus capitis, or the Head Louse (Fig. 47), is considerably smaller 
than the body louse. Its legs are larger in proportion to the size of the body 
than those of the P. corporis; and the abdomen is more distinctly divided into 
seven segments, separated from each other at the margins by deep notches. 

They propagate with astonishing rapidity, and by their irritation produce 

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TOPICS RELATIVE TO PATHOLOGY. 



Fig. 47. 



an eczema, fromwhich tlie fluid exudes abundantly, and crusts are formed, 

involving the cuticular debris or exuviae 
of tbe lice and the remains of epidermis. 
The hairs become glued together ; partly 
by the fluid from the eczema and partly 
by the secretions of the insects as they 
deposit their ova in the capsules which 
they fix to the hairs (Fig. 48). These 
capsules are commonly called nits; and 
they adhere with great tenacity to the 
hairs. 

38. Pediculus palpebrarum, the Louse 
of the Eyebrows, is a doubtful variety. 

39. Pediculus vestimenti. — The Body 
Louse f Fig. 49) is of a whitish color, and 
varies from half a line to two Hues in 
length ; the body elongated and the ab- 
dominal portion broad, its margins lobu- 
lated and covered with little hairs. The 
thoracic portion is very narrow, and car- 
ries three legs on each side. The legs 
are hairy, jointed, and terminate in claws. 
The insect secretes itself amongst the folds 
of the clothing, and causes extreme itchi- 

Betweeu the irritation of the insect, the 




(a) Pediculus capitis (male); {b) Trachea and 
stigmata ; (c) Anteuna (after Andehsonj. 



ness of the skin where it comes to feed. 



Fig. 48. 




lOOths of an inch X 200 diameters. 
Kit, or Egg Capsule of tlie Louse, lixed to (b) a hair, by the glutinous secretion (p, c, c, c). 

debris of its exuviie, and the scratching of the skin by the patient, papula arise, 
the summits of which being torn oflT, give rise to a pruriginous eruption, which 



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TREATMENT OF LOUSINESS. 215 

may even become pustular. This eruption is met with most frequently on 
the neck, back, and shoulders, and round the waist — the parts most tightly 
embraced by the clothing; and where the clothes 
are most frequently gathered iuto folds, between riG.49. 

which the lice are imbedded, and where they de- 
posit their eggs, or egg capsules, which are crystal- 
line, shining, yellowish, opaque bodies. The lice 
seem to multiply fastest where eruptions, such as 
eczema, prevail. A case is reported by Mr. Bryant 
as having occurred in Guy's Hospital, in which the 
whole of the body was literally covered with lice. 
The patient had been a governess, about thirty 
years of age ; and the irritation was so great that 
excoriations and scabs were produced. On admis- 
sion into hospital she was put into a warm bath, 
her clothes were destroyed, and every precaution 
taken to remove all the insects ; but in two hours 
afterwards her body was again covered with lice, ' ' ''''''''' 
although she had been laid in a clean bed. She ^'Z^lV^'^^^ZZr 
was again thoroughly washed, but the vermin re- * "^ '"aSjeeson)"""' 
appeared immediately. Some of the insects and 

their ova no doubt remained adhering to the skin, hidden amongst the scabs 
of the excoriations ; and they are known to multiply with a rapidity propor- 
tioned to the favorable nature of the soil afforded by the morbid condition of 
the skin of the affected person (Anderson, I.e., p. 108). Bernard Valentin 
relates the history of a man, forty years of age, afflicted with unsupportable 
itching over the whole body, and having his skin covered with little tuber- 
osities. The physician, unable to assuage the itching, made an incision into 
one of the small tumors, and gave exit to an enormous quantity of lice of 
different forms and sizes. The same operation was performed on the other 
tumors with a similar result (quoted by Andeeson, p. 110). The following 
instance is related by Dr. Whitehead, in his work On the Transmission from 
Parent to Offspring of some Forms of Disease, p. 173, and quoted by Dr. 
Tanner: A farmer forty-three years of age, strong, and of sanguine com- 
plexion, contracted syphilis in April, 1840. Seven months afterwards he 
suffered from secondary symptoms. At the end of 1841 he became so an- 
noyed by the presence of lice about his person, chiefly on the trunk, that he 
sought again medical aid and advice. He was scrupulously clean in his 
habits, and had never before been troubled with these vermin. They in- 
creased in number, and produced such mental distress that fears were enter- 
tained for the integrity of his intellect. An examination of the skin showed 
a multitude of irritable-looking points on the front and sides of the chest, 
fi'om which 7iits could be detached by lateral pressure. At this period the 
generation of the lice was so considerable and rapid that a flannel vest put on 
clean in the morning was crowded with them by the end of twenty-four hours. 
The usual remedies had only a temporary effect, till iodide of potassium and 
prussic add, taken internally, seemed to render the system unsuitable for the 
further development of the vermin. 

40. Pediculus tabescentium, or Distemper Louse, is^ of a pale yellow color, 
having a rounded head and long antennse ; the thorax is large and quadrate, the 
abdomen large, and the segments intimately united. It is doubtfully British. 

Treatment of Lousiness consists in tbe destruction of the insects and sooth- 
ing the irritation. To accomplish the death of the parasites the following sub- 
stances are efficient — namely, carbolic add, sulphur, mercury, staphisagria, 
sabadilla, pyrethrum, the essential oils, and alcohol (Anderson). 

Carbolic add may be used as a soap (Calvert's or Macdougal's), or oint- 
ment, or as a lotion, in the following proportions : 

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TOPICS RELATIVE TO PATHOLOGY. 



Crystallized carbolic acid, two drachms ; Spirits of Rosemary, one ounce ; 
Eectified spirit, half an ounce : Distilled water, to make up a lotion to six 
ounces, with which the parts are to be sponged night and morning. 

Sulphur is used in the form of vapor baths or fumigations, or the simple or 
compound sulphur ointment of the Pharmacopoeia. 

Mercury may be employed as simple mercurial ointment, or by fumigations 
with cinnabar, or in solution of the bichloride, in the proportion of two to 
three grains to an ounce of water, to which some alcohol has been added. 

Staphisagria is employed as an ointment in the proportion of an ounce of 
staphisagria with four ounces of lard ; or an infusion of staphisagria may be 
made with vinegar. 

Sahadilla may be used in powder or as an ointment ; an ounce of lard being 
used to incorporate a drachm of sabadilla. 

The hair should be cut short when lice infest the head ; and a lotion of the 
bichloride of mercury, or some of the ointments above named, applied at once 
to cause the death of the insects. The nits may be dissolved away by alcohol or 
dilute acetic acid (Hebra). The scalp should afterwards be repeatedly washed 
in warm water with soap, and the eruptions treated according to their nature. 
Sometimes the nits and the debris of the lice are involved in the substance 
of these eruptions, so that care must be taken to kill any insects that may 
remain and be so hidden. 

With regard to body lice, it is necessary either to destroy the clothes or to 
expose them to a temperature of at least 150° Fahr., by steaming them, or 
ironing them over with a sufficiently hot iron, or to boil them. In extreme 
cases, such as those related at p. 215, it has been found that a mixture of 
iodide of potassium and prussic acid in full doses cured the diseased state of 
the system which favored the development of lice in such numbers. After 
sixteen or eighteen doses in the case recorded by Whitehead, the cure was 
permanently completed. 

The Pedicidus jnibls is best got rid of by rubbing a lotion of bichloride of 
mercury amongst the roots of the hairs, taking care that it is brought in con- 
tact with every insect. The 
application should not only 
be applied to the hair of the 
pubis, but to that in the 
neighboi-hood, such as that 
of the scrotum, perinceum, and 
anus; and the ajiplication 
should be continued twice a 
day for a week at least. Mer- 
curial ointment is equally ef- 
ficacious ; but care must be 
taken not to induce saliva- 
tion : the hairs, rather than 
the skin, are the parts on 
which the lotion or ointment 
ought mainly to be applied. 

41. Sarcoptes scabiei. — 
The full-grown itch spider or 
Acarus is of a whitish-yellow 
color, and is just visible to the 
naked eye. The female (Fig. 
50) varies in size from ith to 



Fig. so. 




|th of a line in length, and 
to -^th of a line in 



Acarus scabiei.— tenvAa (after Dn. T. Andeeson). 



from j\-jth 

breadth. It is of an ovoid 

form, broader anteriorly than 



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DESCRIPTION OF THE ITCH SPIDER. 217 

posteriorly. The anterior segment carries the head and four limbs, two on 
each side of the head, which are set very close to it. The head projects con- 
siderably beyond the body, is of a rounded form, and marked by a central 
fissure provided with mandibles. The limbs are altogether eight in number, 
the four posterior limbs being placed about the middle of the under surface of 
the body. These limbs are of a conical form, tapering towards a point. They 
are each composed of several jointed segments ; and the four anterior limbs 
are each provided with a stalked sucker. The extremity of each of the hind 
limbs terminates in a long curved hair ; and several short hairs spring from 
beside the root of each sucker on the anterior limbs. The body is marked by 
numerous regularly disposed wavy lines ; the dorsal surface is convex, pro- 
vided with numerous little angular spines and little round tubercles, from 
each of which also springs a short conical spine. From each side of the body 
two hairs project ; and four project posteriorly ; so that, including those 
springing from the hind legs, the posterior half of the body is provided with 
twelve long hairs. 

The male Acarus seabiei (Fig. 51) is considerably smaller than the female ; 
and the innermost pair of posterior limbs are provided with stalked suckers 
as well as the anterior limbs ; while the parts corresponding to the genital 
organs are very distinctly marked (Hebea, 
Anderson). fig.si. 

It is now impossible to say who discovered the 
itch insect. Avenzoar hinted at the existence 
of an insect in the vesicles of itch ; but Moufet, 
in his Theatrum Iiisectormn, first mentioned it in 
a particular manner in 1663. Hauptmann first 
published a figure of it, and represented it with 
six feet. Redi Lorenzo, Cestoni, and Bonomo ex- 
amined numbers of them, having removed them 
from the papules or vesicles of the skin. They dis- 
covered also the eggs of the parasite, and even ob- 
served their extrusion. Morgagni, Linnaeus, De 
Geer, Wichmann, and Waltz confirmed these ob- 
servations ; but, nevertheless, the existence of the 
parasite up till 1812 was still called in question. 
About this time, therefore, a considerable prize 
was ofiered by the Parisian Academy of Sciences 
for its demonstration ; and M. Gales, an apothe- 
cary of the St. Louis Hospital, tempted by the reward, is said to have defrauded 
the Academy and gained the prize (Anderson). His investigations are re- 
ported to have been witnessed by many members of the Institute ; but never- 
theless, he managed to conceal beneath the nail of his thumb the common 
cheese-mite, and having opened with a lancet the pustule of a patient affected 
with scabies, he dexterously produced the cheese-mite from beneath his nail, 
pretending to have removed it from the patient (Anderson). Many others 
attempted to find the Acarus in the pustules or vesicles ; and the circumstance 
of such men as Galeoti, Chiarugi, Biett, Lugol, and Mourouval having failed 
in finding the animal, occasioned fresh doubts regarding its existence. Their 
failures arose from having followed the cue given them by M. Galls in search- 
ing for the parasite in the papules or vesicles. Moufet had long before stated 
that they were not to be found in the pustules, but by their sides. Casal 
made nearly a similar observation ; and Dr. Adams remarks that they are 
not found in the vesicles, but in a reddish line going ofi" from one of its sides, 
and in the reddish firm elevation at the termination of this line, a little dis- 
tance from the vesicle. Seventeen years after Gales's demonstration the 
Academy discovered, through Easpail, that they had been defrauded ; and 
in 1834 M. Renucci, a medical student from Corsica, showed the physicians 

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218 



TOPICS RELATIVE TO PATHOLOGY. 



of Paris the mode of discovering the Acams, "which is the same method as 
that which had been formerly mentioned by Dr. Adams. Since that time, as 
Rayer remarks, the existence of the A. scabiei has been placed beyond a 
doubt ; and after the demonstrations of MM. Lemery, Gras, and Eenucci 
(all of whom showed him the method of detecting it ), Rayer has been able to 
extract it several times himself. Raspail has given an excellent description 
and figure of the parasite. M. Albin Gras enters into researches as to the 
share it has in producing the eruption, and he instituted experiments on the 
Aearus itself, which have an important bearing on the treatment of scabies. 
The habits and natural history of the parasite have been carefully investi- 
gated by Hebra ; and Dr. Anderson has given an excellent account of these 
investigations, from which this description of the parasite and the disease is 
mainly taken. 

The discovery of the male Acarics is claimed by several observers. Accord- 
ing to Hebra, it was first discovered by Danielssen and Boeck in Norwe- 
gian scabies. According to Dr. Anderson, M. Bourgogne, the maker of 
microscopic preparations in Paris, claims to be the discoverer. According to 
Devergie, the honor is due to M. Lanquetin, a pupil of St. Louis. 

It is the female only which burrows in the epidermis of the human skin. 
All the male Aeari go free on the surface of the epidermis, where sexual in- 
tercoui-se laetween male and female Acari is said to take place. When an 
impregnated female is placed on the surface of the skin, it seeks a suitable 
spot to penetrate, and raising its head at right angles to the surface, it digs, 
burrows, or eats its way between the scales into the deep layers of the epider- 
mis, where it imbeds itself, derives nourishment, and goes through the process 
of paturition till she dies. Having found a suitable place, an egg is laid, and 
each day another, the animal penetrating a little further each time, leaving 
its deposited eggs to occupy the space previously inhabited by itself. The 
direction of the canal is ololique, the portion first formed being of course, 
nearest the surface. As the old epidermis is thrown off, new layers of cuticle 
being formed from the deeper strata, the first-laid eggs are gradually thrust 
upwards to the surface, where they are finally extruded, while the recently 
deposited ova remain in the canal close to the parent female, whose instincts , 
lead her to make the canal in such a way that her eggs reach the surface 
about the time the young ones are ready to come out of the shell. The newly- 
hatched Acari (males and females) having arrived at the surface, crawl about 
the skin, and enter into sexual congress. The females in due time become 
impregnated, and, like their parent, repeat the process of burrowing and par- 
turition just described. The length of time which intervenes between the 
laying and hatching of an egg is said to be fourteen days ; and as the Aearus 
is found to lay one egg daily, there are rarely more than fourteen eggs in one 




(a.) Erk in the first staR-B; (S.) In the second stase, their granular contents being yellow ; (f.) Egg in ' 
the third stage, the form of the Acnrui becoming apparent; (</.) The egg in the fourth stage, the Acarvs 
having broken the shell; (e.) Eggshell after the escape of the Ai-arus (after Dk. T. Andeeson). 

canal at a time. The canals (cuniculi) which the female Acari burrow have 
a serpentine shape, and vary from half a line to three lines long. Hebra and 
Dr. Reid, of Glasgow, have seen them three or four inches in length; and 
HelH-a mentions that they sometimes completely surround the wrist like a 



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DEVELOPMENT OF THE ITCH SPIDER. 



219 



Fig. 53. 




Larva or young Acaru^ scabiei — 
having only two hind legs (after 
De. T. Andeeson). 



bracelet. These canals have generally a whitish dotted appearance, the dots 
corresponding to the ova in the canals ; and at the extremity of each canal is 
a little whitish elevation, which corresponds to the site of the parturient or 
defunct female Acarus. This whitish elevation is generally about a quarter of 
a line distant from the papule or vesicle ; and the skin should be cleaned 
before endeavoring to detect it. After the death of the mother Acarus, the 
epidermis which covered in the canal gives 
way, as the cuticle grows and desquamates; 
there is then left at first a depression, or open 
rugged fiirrow bounded on each side by a rag- 
ged edge of epidermis ; and as these edges 
become dirty, the remains of the canal present a 
dirty ragged liae. Besides the Acarus and its 
eggs, numerous little oval or rounded blackish 
spots are seen in these canals, which are supposed 
to be the excreta of the parasites ; and after the 
female has once entered its canal it is unable to 
recede, owing to the spines on its body, which 
project backwards. It therefore dies in the canal 
when parturition is finished. The eggs of the 
Acarus vary much in size, according to their age 
and development ; and just before the larva has 
burst its shell the egg is almost as large as the male Acarus. In the earliest 
stages the egg is very small, and filled with a granular-like matter (Fig. 52, a). 

It grows in the canal ; and as it increases in size its con- 
tents seem to shrink and recede from the shell, and to have ^^®- 5*- 
a distinct enveloping membrane. The bright yellow color 
of the embryo contrasts strongly with the clear, almost color- 
less, walls of the eggshell (Fig. 52, h, c, d). The head and 
legs of the embryo soon become distinctly visible, and at 
last the whole form of the Acarus (Fig. 52, c, d). Finally, 
the shell bursts, and the young Acarus escapes, leaving its 
shrivelled envelope (e) behind. The larva or young (Fig. 
53) differs from the full-grown insect in the possession of two 
hind limbs only, in place of four. By and by, however, 
it casts its coat, and then appears with eight legs ; and 
sometimes even the full-grown Acarus, with its eight legs, 
may be seen inside of its old six-legged skin, and thus ren- 
ders the history of its development complete. 

42. Demodex folliculorum is found inhabiting the sebace- 
ous sacs and hair-follicles of the human skin (Fig. 54). By 
some naturalists this parasite is referred to the Acaridcc, but 
by recent investigations it is considered to be more nearly 
related to the Rotifera, its parasitic habits causing it to 
resemble some of the numerous forms of the Crustacea. It 
is not known to cause disease or any specific lesion. 

43. Pulex penetrans, Chigoe or Jigger, is a species of flea, 
and one of the greatest pests in tropical countries, and espe- 
cially in South America and the West Indies. The female 
burrows in the skin of the feet till quite out of sight, pre- 
ferring the bare spot between the toe and the nail, and 
there remains to rear a numerous progeny. It sets about 
its work so quietly, and insinuates itself so gently, that the 
only perceptible sensation is a slight, but not unpleasant, 
irritation (Rev. J. G. Wood). When the female has com- 
pletely penetrated under the skin, the vast number of ova 
begin to undergo development, and so enlarge the parent-abdomen of the 



Demodex foUiculO' 
rum (after Dr. An- 
derson). 



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220 TOPICS KELATIVB TO PATHOLOGY. 

Chigoe to about the size and shape of a pea. Even when so large, the only- 
external sign is the swelling, with livid bluish color surrounding it, and up to 
this time it may escape observation. Those, however, who live in Chigoe-m- 
fested districts are careful to examine their feet every day, and dislodge the 
insect at an early period with the point of a needle. It is very difficult to 
extract them when fully swollen ; for if the distended abdomen bursts, and a 
single egg is suffered to remain, the larva will be hatched in the wound, severe 
inflammation results, and a painful, festering, troublesome sore remains. If 
such a consequence supervene, oil of turpentine dropped into the wound is the 
most efficient, though painful remedy, but preferable to the long-continued and 
future painful sores. The negroes use red pepper, which they rub well into 
the hollow after extracting the rest of the Chigoe from the feet of children ; 
and the children are so afraid of being peppered that they soon learn to apply 
early to have the Chigoe removed before it has completely penetrated the skin. 



III. — Entophyta and Epiphyta. 

These mainly consist oi fungi ; but as fungi are often confounded with algce 
and confervce, the following three definitions may be given : 

Definition I. — Algce are represented by sea-weeds and multifarious green vege- 
table forms of simple cell-strueture. They are met with in all streams, ditches, 
ponds, or even in the smallest OGCumulation of water standing for any length of 
time in the open air. They are common also on damp walls, or on the ground in 
all permanently damp places. 

They are represented by the following groups : 

(ffl.) Floridece; (6.) Fuooidece; (c.) Confervoidece. 

The following were once classed as algse, but are now regarded as the myeelia 
of various fungi, and not independent organisms, namely : 

CryptoeoccecB ; Leptomitece ; and Phceonemece. 

Definition II — Confervce or Confervoid Algce are chiefly marine ; and eon- 
. sist of plants having unbranohed filaments, composed of cylindrical cells, the 
length and diameter of which have a very variable relation in different species, 
They are produced from Zoospores, having two or four cilia. 

Definition III. — Fungi are a class of cellular flowerless plants, growing in or 
upon drnnp mould; in or upon the wood and herbaceous parts of living or dead 
plants; upon living or decaying animal substances, or in solutions containing 
organic matter. 

They do not appear capable of assimilating inorganic food, and are in this 
respect distinguished from healthy specimens of all other plants, as also by 
the total absence of color, depending on the presence of chlorophyll or of its 
red modifications. They are allied by certain forms with the algoe. and with the 
lichens ; but are distinguished from all outwardly similar forms of algce by the 
spore-bearing fruit always being elevated into the air, when mature, although the 
thallus or mycelium may be aquatic. 

The lichens possess green gonidial cells in the thallus, which fungi have 
not. They are entirely aerial incrusting plants, while the fungi have their 
vegetative structures immersed in the medium in which they grow. 

As influencing disease, fungi have certain peculiarities : 

(1.) They all absorb oxygen, and give off" carbonic acid. They have great 
powers of decomposing salts of metals, as well as of destroying organic sub- 
stances. 

(2.) All of them contain a greater or less proportion of poisonous alkali 
entering into their composition. 

(3.) Yeast formations produce diarrhoea (Pereira's Materia Medioa, p. 588). 

The Structural Elements of Fungi are— (1.) Mycelium (thallus fibrils), or 
vegetative structure, consisting of threads of various shapes and sizes, com- 



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STRUCTURAL ELEMENTS OF FUNGI. 221 

posing a mass of exceedingly delicate, sometimes jointed and branched, col- 
orless, interlacing filaments. Some are large convoluted tubes, sometimes sep- 
tate, and thej form together a cottony or felt-like mass when growing in or 
upon any permeable structure ; or cloudy flocks when growing in liquids 
undergoing fermentation or putrefaction. The contents of the tubes and 
threads are granules or cells. 

(2.) Reproductive structures or fruit of fungi differ extremely in appearance 
in the various tribes. A filament rises up from the general body of the myce- 
lium, and at its terminal end is borne the fruit, composed of a modification of 
one or more terminal cells. Thus the fruit may either be an enlarged, termi- 
nal, solitary cell ; or a shortly-jointed tube ; or a clustering of minute cells 
seated upon a receptacle ; or a radiate arrangement of minute cells ; or a large 
sac filled with minute cells. 

Reproductive cells or fruit may be of at least three different forms in oonio- 
mycetous fungi. 

(a.) Coiiidia (naked spores), rising direct from the mycelium, or from the 
stroma found on the mycelium. 

The stroma consists of an indefinite number of minute cells, and is the early 
condition or nuclear form of the fully developed fungus. It accompanies all 
fungi in a state of active growth. The nuclear cells sometimes exhibit a molec- 
ular movement of their contents. 

(b.) Conceptaoles, or hollow cells (organized immediately on the mycelium), 
the inner wall of which is lined by filaments (stylospores) terminating in 
minute cells or spores ; or by spermatia, which are much smaller than the 
stylospores,. and of a linear form (ultimately confused into a gelatinous mass). 
The functions of these spermatia are unknown, but are supposed to be fer- 
tilizing. 

(e.) Another form of spore is found inclosed in asd. 

Structure of the Spores of Fungi. — They are round or oval, solitary or 
arranged in rows, single or many-piled, or in groups of various sizes. They 
often show a dark spot, or a nucleus or nucleolus, in their interior. 

The spore has an outer coat composed of cellulose, and an inner coat or 
utricle inclosing a liquid containing floating granules, which are colored blue 
by iodine. 

Spores may be confounded with many other cells, such as fat, blood- 
disks, corpuscles of various fluids, nuclei of epithelial cells, pus, earthy 
particles. 

They are unafiected by ether, chloroform, alcohol, — all of which dissolve 
fatty cells, and render epithelium transparent. 

Ammonia render's the spores a little more colorless. It also dissolves pus 
and the secretions of eruptive diseases (which often contain granules and cells 
very like spores), converting them into a gelatinous mass. 

A hot solution of potash with alcohol dissolves impetiginous crusts, fat, pus, 
hair, and epithelium. 

Earthy particles, in granular, duplicate, or quaternate forms of carbonate 
and phosphate of lime, are destroyed by acids. 

The greatest care must be taken to distinguish fat-cells from spores, and 
diffused molecular fat from sporules, or nuclear forms of fungi. Beware also 
of taking minute fibres from handkerchiefs or towels for mycelia. 

The following are the most useful reagents for determining the character 
of fungi : 

Iodine (solution for granules of spores), Ether, Chloroform, Spirits of Wine 
(absolute alcohol), Ammxmia, Potash, Acids (to dissolve earthy carbonates),- 
Glyeerin, Sulphuric Add. 

The use of reagents is absolutely necessary in determining fungi, to escape 
from constant sources of fallacy. 

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222 TOPICS KBIiATIVB TO PATHOLOGY. 

Although much has been written on the influence oi fungi in the productiou 
or aggravation of disease in the animal as well as in the vegetable kingdom, 
and also as to their influence in the transmission, propagation, or portability 
of disease, yet the subject is involved in much confusion; because, in a few 
instances only, have the persons recording their experience been sufficiently 
acquainted with the botanical nature of fungi, on the one hand, and with the 
nature of diseases, on the other, so as to give anything like a complete history 
of the cases which have fallen under their observation. Mere mycelia have 
been described as perfect plants, and mistakes have been made in impor- 
tant points of structure. Productions of an undoubted fiingic nature have 
been referred to algcs, although agreeing with them neither in habit nor in 
physiology. The commonest moulds have received new names ; and several 
conditions of the same species have been recorded as productions differing in 
their mechanism and physiological laws (Beekeley). 

Fungi are the most numerous of all plants in regard to genera and species, 
and their growth may be associated with most extensive injury to animal and 
vegetable life ; and as they are now proved to be capable of propagation by 
implantation from animals and vegetables to man, they demand from the 
physician a most careful study. The epiphytic diseases of plants as well as 
animals have hitherto been almost neglected by the pathologist ; yet how do 
we know that the blights of plants, or the causes of them, are not communi- 
cable to animals and to man ? It is known how intimately the diseases of 
man and animals are related with the occurrence of famines and the prevalence 
of unsound or unwholesome food, and of famines with the diseases of vegetable 
and animal life, as much as with the destruction and loss of food. The black 
sporules of Ustilago hypodytes, which cause disease in grasses in France (the 
grass smut), and those of Ustilago vittata, which cause similar disease in the 
grasses of India, are known to produce most injurious effects upon the 
haymakers in the former country (Leveille). In places favorable to the 
multiplication of fungi they often commit extensive ravages. Among the silk- 
worms in the silk manufactories of Italy, fungi are the cause of more exten- 
sive destruction of such animals than we have any correct idea of Under 
the names of "mildew," "blight," "smut," "brand," and the like, fungi are 
described as committing extensive damage among living plants, as the farmer 
and orchardist know too well. It has been asserted theit fungi are uncommon 
in tropical countries ; but it is doubtful if this is true; and the fungus disease 
of the foot in India, so well described by the two Carters, shows that fungi 
are capable of giving rise to a disease almost dangerous to life in that country. 
It therefore behooves the pathologist to study carefully the nature of those 
epiphytic diseases in animals and vegetables, as well as in man, whenever he 
has an opportunity, and especially in India. It is not in all cases easy to 
determine whether they are the cause of morbid states, or whether, as some 
think more likely, the diseased tissues has merely afforded a suitable nidus 
for their development. It is certain that wherever the normal chemical pro- 
cesses of nutrition are impaired, and the incessant changes between Solids and 
fluids are less active, then, if the part can furnish a proper soil, the crypto- 
gamic parasites will appear. The soil they select is for the most part com- 
posed of epithelium or cuticle, acid mucus or exudation. Acidity, however, 
though favorable for their growth, is not indispensable ; since some of the 
vegetable parasites grow upon alkaline or neutral ground, as on the ulcera- 
tions' of the trachea, or in fluid in the ventricles of the brain. Certain atmos- 
pheric conditions seem favorable to the occuri-ence of those vegetable parasites. 
For example, Tinea tonsurans may be quite absent for years in places such as 
workhouses, where it commonly exists, and then for several months every 
second or third child in the place gets the disease. It has been observed that 
some of these parasitic diseases can be propagated by transference of the plan 



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I 



PATHOGNOMONIC SIGN OF FUNGIC LESIONS. 223 

as in various forms of tinea, and that the disease can be cured with the greatest 
readiness by the chemical agents which are most destructive to vegetable life. 

Parasites of the nature of fungi, associated with the skin diseases described 
as "ringworm," have been shown to be capable of transmission from animals 
to man. It has been proved by.Devergie that T. tondens, for example, is 
transmissible by contagion from horses and oxen to man, and that the para- 
site has given rise either to the same form of tinea disease or to another; but 
he ascribes both species of parasitic disease to the growth of one and the same 
parasite — namely, the Trichophyton. Von Barensprung, of Berlin, bears sim- 
ilar evidence. He rubbed on his forearm some of the scales of tinea from one 
of the lower animals, containing abundance of the spores and mycelium of 
the ftingus Trichophyton. No effect was produced for several days ; but after 
a longer interval considerable itching called his attention to the part, which 
he found occupied by a well-marked spot of T. dreinatus about the size of a 
sixpence. In three weeks the patch increased to the extent of a crown-piece 
{Brit, and For. Med.- Chir. Review, July, 1857, p. 263). 

Instances have been noticed of grooms being attacked by T. dreinatus and 
sycods after grooming horses affected by T. tonsurans. " A dragoon came to 
the Dispensary of the St. Louis Hospital affected with T. cirdnatus on the 
front of the right forearm. He stated that five or six of his comrades had ' 
contracted this affection as well as himself from grooming diseased horses. A 
visit to the barracks showed three horses with round patches absolutely iden- 
tical with T. tonsurans. These were situated on the withers, shoulders, back, 
and belly. The hairs in the centre of each patch were broken off close to 
the skin, and there was a whitish, squamous, crust-like production, which was 
traversed by the hairs. The presence of sporules was detected by the micro- 
scope. The dragoon who showed the horses showed also his daughter, a girl 
of eight or ten years of age, the side of whose nose exhibited a patch of T. 
dreinatus " (Bazin, quoted by Dr. Anderson, On the Parasitic Ajfeetions of 
the Shin, p. 51). 

With regard to the transmission of favus from the lower animals, I am 
informed by Dr. Anderson that, in the Dispensary practice of Glasgow, the 
physicians often find it traceable to contagion from mice, cats, and dogs simi- 
larly affected ; but that mice especially are the animals which seem to be the 
ultimate source of the disease. 

On the other hand, it is shown that animals may contract parasitic diseases 
of the skin from human beings similarly diseased. Dr. Fox mentions an 
instance of a white cat, a great pet with the children of a family of nine, 
which contracted the mange and T. tarsi from T. tonsurans affecting five of 
the children. The fungus of the mange in the cat is the same fungus as that 
of Tinea in man — namely, the Trichophyton. 

The principal vegetable parasites associated in man with special morbid 
states are enumerated at p. 147, ante; but it would have been better if these 
fungi had been described in the first instance without specific names. The 
fact of specific names having been assigned to each of them has drawn atten- 
tion from the important part which these fitngi perform in the work of de- 
composition. They may be forced to fructify by placing them in a globule of 
water surrounded by air, and placing them in a closed cell ; and until the 
fungus has thus come to maturity, it is worse than useless to give them names ; 
so many different forms in an undeveloped state being all capable of refer- 
ence to one common mould (Berkeley). 

The plants forming on mucous membranes, or in the contents of cavities 
lined by mucous or serous membrane, are in most cases secondary forma- 
tions only, and their exact pathological significance is unknown. 

The pathognomonic sign of all the fungic parasitic lesions of the surface 
(cutaneous or mucous) in man and animals is the infiltration or destruction of 
hairs (tince) and epithelial textures (muguet, thrush, oidium) by the sporules 

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224 TOPICS RELATIVE TO PATHOLOGY. 

of a fungus, and which, by union or by growth, form elongated branches, or 
mywlkmi* 

The diagnosis of such fungi on the skin, hair, or epithelium, can only be 
effected by a careful and skilful microscopic examination ; and it is always 
absolutely necessary to use liquor potasses and other reagents, mentioned at p. 
221, ante, in the examination of all tonsurant appearances of the hair, of all 
idiopathic bald patches, and of all brown or yellow-colored scurfs, for sporules 
are frequently detected which had escaped observation before liquor potassw 
had been used (Bazin, Fox, Andersonj. Sufficient time must also be al- 
lowed for the parts to become transparent under the action of this reagent. 

The parasitic lesions of the skin are, as a rule, unsymmetrical, and hence 
they differ materially in this respect from syphilitic cases. They differ also 
no less essentially from the eruptive diseases of the skin. An eruption is no 
necessary part of these parasitic lesions; but, from the irritation established 
in the true skin, eruptions of various kinds may occur. Eruption thus often 
precedes the detection of a fungus, and, as a rule, very often follows its exist- 
ence ; and they who dispense with the microscope in the diagnosis of skin affec- 
tions cannot avoid confounding severe eruptive with parasitic lesions, because 
they disregard the pathognomonic evidence of such lesions already indicated 
(Fox ). The term herpes, therefore, as applied to these parasitic affections, 
is an objectionable term ; because it has been already used to indicate a vesic- 
ular eruption, namely, herpes zoster, which invariably exhibits large typical 
vesicles. 

There seems to be a peculiar condition of nutrition best fitted for jsarasitic 
growths of a vegetable nature, just as some constitutions and states of the 
system are best suited for the propagation and development of entozoa ; but 
the exact circumstances wdiich predispose to the growth of these entophytic 
fungi upon the human body are not better known than those which predis- 
pose the body to receive and develoj) certain morbid jjoisons of a specific 
kind, known to multiply during the course of the disease, and to throw off 
material cajiable of propagating and spreading the same kind of disease. 
With regard to the parasitic diseases of the skin and hair, a failure of the 
vital powers to carry on tlie healthy pr(5cesses of life seems ordinarily to be 
one of the inviting causes of such a development of true fungi as would con- 
stitute a disease. A sjsecial nidus or soil is necessary, just as a predisposition 
is necessary in the case of the spread of miasmatic diseases ; yet care must be 
taken in botli instances not to confound the co-operating cause with the special 
or peculiar poison or germ. Both Robin and Bazin recognize a condition of 
the hairs (dependent, perhaps, on constitutional causes) which appears to be 
essential for the growth of the plant; for simietimes the disease disappears 
spontaneously, and the fungus dies without its being destroyed by any specific 
treatment. 

Varied opinions still prevail regarding the nature of vegetable parasitic 
affections, and especially as to whether several distinct fungic growths are 
conceived in the production of the parasitic affections of the skin ; or whether 
those affections are due to one and the same parasite. It has been shown 
that all the forms of ringworm are due to the same parasite, — namely, the 
Trichophyton (Bazin, Anderson); but there are not a few who hold that 
there is only one parasite productive of all the vegetable parasitic affections 
of the skin, amongst whom are the names of Hebra, Tilbury Fox, Lowe, and 
Jabez Hogg. 

Tliere are numerous facts which seem to them to justify the belief that 
there exists but one essential fungus, whose sporules find a soil for develop- 
ment and growth upon the surface, or even within more secluded portions of 

* These fiuiffi have sometimes been popularly but erroneously termed conferva. 
The conjervce for the most part grow in salt or tVesh water. 

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NON-IDENTITY OF PARASITIC FUN&I. 225 

the human body ; and that varieties in the growth of that fungus are due to 
differences in the constitution of the individual, to the moisture, exudation, 
soil, or temperature under which the development of the fungus takes place. 
The exact nature of these differences is not yet understood ; but the produc- 
tion of irritant acids and gases are constant accompaniments of the growth of 
such parasites, by the chemical action of the vegetable cell; for it does not 
undergo development without exciting a chemical decomposition in the pabu- 
lum on which it feeds ; and the different stages in its growth give rise to alco- 
holic acid and putrefactive fermentation. Of the latter there is ample evi- 
dence in many of these parasitic skin diseases, and especially in favus, the 
odor of which closely resembles that of some methylamine compound (Lowe). 
Thus their irritant action very soon may establish an eruption. But the ratio 
of eruption to parasite is not constant ; for an amount of fungus which will 
simply produce death of hair in one person or part of the body, may in 
another produce irritation, eruption, or violent inflanunation. These different 
. results may be due to two causes, — (1.) Constitutional peculiarity in different 
individuals ; (2.) Peculiarity of structure of a part as regards density, heat, 
moisture, and chemical and anatomical composition of the part. 

On the other hand, Dr. Anderson contends that the fungi met with in 
favus, tinea tonsurans, and pityriasis versicolor, are each different ; in other 
words, that the Aehorion Schonleihi, the Trichophyton, and the Microsporon 
furfur, are not identical. The following is a summary of the proof he adduces 
in favor of their non-identity : 

"(1.) In all cases of successful inoculation with the Achorio7i, Trichophyton, 
and Miotrosporon furfur, the same parasitic disease has been produced as that 
from which the parasite was taken. 

" (2.) Of the innumerable eases occurring in the human subject illustrative 
of the contagious nature of favus, tinea tonsurans, and pityriasis versicolor, 
which have been recorded, there is no authentic case in which one of these 
diseases gave rise to one of the others. 

" (3.) The difference in the appearance of favus, tinea tonsurans, and pityr- 
iasis versicolor, when fully developed, is so very striking, as to lead to the 
belief that they are produced by separate parasites. 

" (4.) There is no authentic instance on record of the transition of one of 
these diseases into one of the others. 

" (5.) The difference in the appearance of the aehorion, trichophyton, and 
microsporon fiirfur, is sufficiently striking to enable the observer in many 
cases to form a correct diagnosis from the microscopic examination alone. 

" (6.) Of the numerous instances on record of the transmission of favus and 
tinea tonsurans /rom the lower animals, by contagion or inoculation, favus has 
always given rise to favus, and tinea tonsurans to tinea tonsurans." 

It is not to be hastily concluded that a disease is non-parasitic because a 
fimgus has not been demonstrated in the part where it was expected to exist.. 
The minuteness of the sporules, and the care required in the investigation, 
sufficiently explain the very various opinions which have prevailed on the 
nature of these parasitic lesions (Lowe). To appreciate the ravages which 
may be produced by such minute cells, the reader may be reminded of the 
immense force which the growth of such cells is capable of producing through 
continuous and gradual development ; for, being of so minute a form, and its 
agency so apparently invisible, its intrinsic power is apt to be underrated. 
An Agaric growing under a stone of more than a hundred pounds' weight 
will eventually raise it from its bed to the height of several inches ; and the 
cells of that Agaric are not widely different from the sporules of a fungus. 
Again, the mycelium of a fungus (probably identical with that found in skin 
diseases) has been known to raise a cask of wine, the fungus feeding on the 

VOL. I. 15 

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226 TOPICS RELATIVE TO PATHOLOGY. 

wine as it leaked from the cask (Harvey, quoted by Lowe iu Lancet of 
August 13, 1859). 

The variations of form in these diiferent vegetable parasites, associated with 
the skin diseases to be afterwards described, are obviously so slight that they 
seem insufficient to warrant different species being made out of them. They 
may all be initial or undeveloped forms, referable to the Aspergillus glauem 
or Penicillium ; the initial forms of bofh of these being isomorphous (Lqwe) ; 
and both of them are also equally indifferent about the matrix where they 
grow, as long as the conditions for their growth are fulfilled (Beekelby). 
Peculiarities have also been observed in the growth of the fungus, which may 
be explained as due to the stage of development and conditions of growth at 
the time it was examined (Path. Society Trails., vol. vii, p. 395). The same 
fungi during their growth are. known to assume very different forms and 
appearances. It thus happens that the same species has not only been de- 
scribed under different specific names, but even referred to different genera. 
Fries states that he has traced no fewer than eight genera of different authors 
to mere degenerations or imperfect states of one particular fungus ( Thelephora 
sulphuria) ; and Nees von Esenbeck states that the same fungoid matter whiclj 
develops a certain fungus in winter (the Sclerotiwn my'cetospora) will develop 
another fungus in summer (the Agarioiis volvacevs). Professor Henslow showed 
that some of the supposed species of Uredo are forms of Pucdnia, Aregma, 
and the like. 

Thus the Di-morphism of fungi presents a difficulty at the outset in connec- 
tion with the identification and interpretation of the structures seen in textures 
which are believed to be infested with fungi. 

In many fungi of the eoniomycetous kinds (where spores are the principal 
part) the same fungus appears under two or more distinct forms — so distinct, 
that some have been regarded as different species belonging to different genera, 
far removed from each other, and bearing different names. 

The golden-colored tumeric-like powder on the under surface of the rose 
leaves has its mycelium penetrating the tissue of the leaves, and the powder 
on the surface is composed of the spherical spores. The plant fungus was 
believed to be here complete, and has had the name of Uredo i?osns given to 
it. But later in the season there are produced on the same mycelium certain 
dark-brown spots, which have been found to be aggregations of complex fruits 
of the same plant. These brown spores are borne on long stalks, and are 
septate or divided by transverse partitions into a complex fruit, to which the 
name of Pucdnia Rosce has been given. 

Thus Uredo Rosse (the yellow spores), and afterwards the Puccinia Rosse 
(the brown fruit), were believed to be distinct and different fungi. Now they 
are knwn to be different forms of fruit on the same plant. 

Multiplicity of form is thus characteristic of the fructification of fungi. 
These forms are one or other of the following : 

(1.) Naked spores, or "conidia" (of which there are at least four forms), 
growing on the external cells of stroma, and reproducing only torula-like 
forms or promyoelium. 

(2.) NaJced spores or conidia, becoming sacs or pyciiidia, and containing true 
minute spores (sporiferous), sometimes septate or bead-like, or moniliform 
strings, associated with true spores, and named stylospores. 

(3.) Spermatia, or minute bodies, produced in cysts or spermogones,andnot 
known to germinate. 

(4.) Cojiceptacfes, containing " sporidia," in hyaline sacs. These "sporidia" 
are secondary sporules, and are thus produced, within asd or sporangia, on the 
germinating threads from the true spores. 

In such fungi the mycelium or root-part consists of fine thin filaments, 
spreading through all parts of the plant infested by the parasite ; and the dis- 
tinctions are taken from the characters and forms of the true spores. 



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-ARTIFICIAL CULTIVATION OF FUNGI. 227 

The artificial cultivation of funffi has lately attracted attention, and it has 
for its object to distinguish the species of fungus under observation. The iden- 
tification 0? fructification and fruit is necessary to distinguish the species ; and 
the only safe method is, — 

Fitst. To identify the germ to be cultivated (the hidividual " micrococcus," or 
larger globule, or spore). 

Second. To take a specimen of " the micrococci," or one or more globules 
or spores, and isolate them in a closed cell, containing suitable food, to germi- 
nate in ; and with a pellicle of air surrounding the food and the germs, into 
which, as they grow, they may throw out their aerial forms of fruit or other 
reproductive parts by which they may be identified. My friend. Dr. Maddox, 
recommends the following solution for cultivating microscopic fungi (on glass 
slides) : " Dextrin, phosphate of soda and ammonia, microcosmic salt, of each 
two grains ; grape sugar, sixteen grains ; saturated solution of acetate of pot- 
ash, twelve drops ; distilled water, one ounce, placed in an ounce and a half 
vial set in a saucepan, with sufficient' water to come to the shoulder, and 
boiled for half an hour or longer. Surround the bottle very loosely with bits 
of rag or hay. If wished to increase the temperature, add salt to the water, 
or use a dense fluid, as oil. When cold, pour off" into clean Jij stoppered 
bottles. I find most of the fungi grow well, keeping their color in this fluid. 
Placing the growing slide in a porous (battery) cell, and setting this in a 
vessel with an inch depth of water, keeps the object moist. This cell can be 
opened or covered from the light." * This is the only way to determine what 
originates from such bodies as are termed "micrococci." 

Third. To take care that the menstruum contains no other germs than those 
to be cultivated. 

The growth of moulds on moist substances ought first to be made a subject 
for the practical study of beginners. 

' The pastes of wheat or of rice flour, where such moulds grow, should be 
examined at different depths, when it will be seen that numberless different 
modifications of form are assumed by the same fungus in different parts of the 
matrix. 

The general unsatisfactory character of cultivation-experiments are mainly 
due to two elements : (1.) The difficulty of the work, and the loose mode of 
identifying what has been called " micrococci," or even the larger " yeast-like 
cells." (2.) The uncertain methods of cultivation of these, and their uncer- ■ 
tain identification with known forms of fungi. 

When a spore is taken for artificial cultivation, it is almost sure to carry 

* Purther particulars, accompanied with two plates of figures, showing the results 
obtained with the Aerocor.iscope, described in the Monthly Journal of the Royal Micro- 
scopical Society, June, 1870, on 155 days' exposure, are given in the February num- 
ber of the same Journal, 1871. The following is a brief summary of the method 
adopted : A narrow lined square, |ths of an inch diameter, open at one corner, being 
drawn on a slightly warmed microscope slide, with a sable-hair pencil, dipped in a 
preparation of mastic, wax, chloroform, and turpentine; a droplet of the following 
solution, which, after many trials, was also, by preference, employed for collecting 
the atmospheric particles on the thin glass covers, was placed in the centre of the 
square; the thin cover, with the collected substances, was then laid on this and gently 
pressed down. The slides thus prepared were set in a thin box, made from a new 
large writing-slate, one surface of the frame being slightly deepened by an extra one. 
This surface of the slate, covered with thick white blottiiig-paper, damped with dis- 
tilled water, had placed over it a clean sheet of pierced zinc plate, on which the slides 
were laid ; the thin box was then covered by a plate of glass, made to slide in the addi- 
tional framing, so as to convert the same into a narrow, flat, moist chamber, in which 
the slides were exposed to ordinary daylight. The solution was made from thick trea- 
cle, 1 drachm ; saturated solution of acetate of potash, 40 minims; distilled water, 5 
drachms, boiled in a narrow, covered test-tube until reduced to 4 drachms, the tube 
closed whilst hot, and when cooled and settled, a portion of the liquid poured into a 
2-drachm stoppered bottle, previously washed out with alcohol, and drained. 

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228 TOPICS RELATIVE TO PATHOLOGT. 

with it germs oi Bacteria schizomycetes, or other germs, as these exist in great 
abundance wherever fungi are, and they rapidly develop into an immense 
number of individuals. 

Spores of certain fungi will endure the moist heat of boiling water without 
losing powers of germinating ; their behavior is similar with regard to the 
power of resisting frost ; so that their endurance of high and low temperatures 
is very remarkable (Berkeley's Fungology, p. 32). Hence the very inde- 
structible characters of spores. The smallness of the reproductive cells or 
germs of fungi, and their facility of distribution, are important to be remem- 
bered in connection with their relation to disease-propagation. Some species 
are constantly recurring in the same places ; but there is nothing like chance 
about their characters and growth. So rapid are they in development, that 
their appearance seems to favor the idea that they cannot have grown from 
seeds, germs, or spores. But notwithstanding the recent revival of the ques- 
tion of spontaneous generation, and of Professor Bastian's and Huxley's 
results, the belief in such generation is surely exploded,-^all the more surely , 
after the recent repetition of the experiments by Professor Frankland, of St. 
Bartholomew's Hospital. The most careful experiments show that without 
pre-existent germs no organized beings are ever produced from solutions con- 
taining material fit to nourish animal or vegetable life. Where experiments 
are not careful, and propor precautions are not taken to exclude germs, they 
grow and will exist in myriads. Observations on the growth of germs must 
be made very often, in some cases hourly. Only very little material should 
be employed at a time (a single germ only, if possible), in order that the field 
of observation may be well known and clear. 

The object is to see actually that a given growth proceeds from a given 
origin ; and not to conclude that when two or more forms exist in the same 
preparation, that they necessarily have a developmental relation to each other 
or a common origin, even although, at the beginning of the experiment, there 
appears to be only one kind of element present. Mere coexistence without 
organic connection afibrds no grounds for such a conclusion. 

The apparatus required for culture-experiments must be of such a kind as 
will aiford — (1.) Means of protection from dust ; (2.) Means of applying 
heat; (3.) Means of growing in the dark; (4.) Means of frequent observation. 

An account of the parasitic diseases of the skin will be found under " Dis- 
eases OF THE Cutaneous System." 



CALCULUS AND CONCRETION. 

Latin Eq., Calculus et Concreia; Fkbnch Eq., Calcul et ■ Concretion ; German Eq., 
Stein und Concretion; Italian Eq., Calcolo e Concrezione. 

Definition. — (a) Calculus is a formation brought about by the deposition of 
all or of certain components of a fluid in which they are naturally held in solution 
or suspension; (6) Concretion is a formation (1) arising out of a liberation of 
lime or other salts (phosphates and carbonates) from- their normal combinations, so 
as to incrust or perietrate parts and sever minute textures (Eokitansky), or (2) 
a formation arising from stagnation of a secretion, when mineral and protein ■ 
compounds alike become solid. 

, Pathology.— Calculi are especially prone to form in secreted fluids, and 
either consist purely of specific ingredients proper to the secretion, or these 
ingredients blended with other elements. Numerous causes contribute to 
their separation : for example,— (a.) Extreme concentration of the fluid from 
loss of water ; (6.) Inspissation and exsiccation of secreted and exuded mat- 
ter, such as mucics, ear-wax, smegma preputii, bile-, pus; (c.) Chemical con- 
version of the fluid, as when the free acid of normal urine retains the phos- 
phatic earths in solution, and when such urine is rendered alkaline, as by the 



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CONCRETIONS OF PROTEIN SUBSTANCES AND FATS. 



229 



presence of mucus, or of pus, or of exudatiou, or by conversion of urea into 
carbonate of ammonia, the phosphatic earths becoming precipitated. If 
lithates present in the urine become decomposed by excess of acid in the 
urine, uric acid, being less soluble, is thrown down as concretions or minute 
calculi. The soluble phosphate of magnesia also becomes a concrete precipi- 
tate the moment it enters into combination with ammonia, as ammonlo-'phos- 
phafe of magnesia. 

The principal and best-known elementary substances which, either in their 
purity or in combination with others, compose the more bulky calculi-concre- 
tions or concremeuts, are as follows : 

1. Concretiom of Protein Substances emerge from their solutions as a struc- 
tureless or clod-like lump, or mass in various degrees of coagulation, or as 
elementary granules, represented under the highest magnifying powers by a 
concrete dot or point. Whatever undergoes spontaneously rapid and ffrm 
coagulation is described as fibrin; that which coagulates more slowly and less 
perfectly, under the influence of heat, is known as albumen. 

The protein deposits are insoluble in ether and mineral acids. Acetic acid 
renders them translucent, and ultimately dissolves them. Caustic jxtash and 
fuming hydrochloric acid slowly dissolve them, the latter with a lilac tint. A 
watery solution of iodine colors them yellow. 

2. Concretions of Fats occur in the elementary form of drops, or as amor- 
phous solid particles, granules, or crystals. There are different kinds of fats, 
recognizable by their forms and chemical relations, namely : 

(a.) Elain or olein, occurring in variously-sized drops, either free or within 
cells. The fat is usually set free out of emulsion-like compounds ; and as 
elaic acid, out of saponaceous compounds ; or out of combination with other 
fats, as in exudations or in medullary cancers. The drops resist the action of 
water and of acids, but dissolve on being boiled with potash, and still more 
readily in ether or heated alcohol. 
, (6.) Margarine and margaric acid occur as microscopic, needle-shaped crys- 

FlG. 55. 

A. 



# 





(B.) Fal-celts, inclosing crystals of marga- 
rinc (AVedl). 



W.) Orystals of m,argarine (after 
Robin and Verdeil). 

tals, generally aggregated so densely in stellate groups or bundles as to 
appear as round, almost black, spherical masses (Fig. .5.5;. Margarine 



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230 



TOPICS RELATIVE TO PATHOLOGY. 



emerges in these shapes from its solution in elain after cooling either within 
fat-cells ( Fig. 56) or free. Crystals of margarie acid, soluble in concentrated 
heated alcohol, are developed out of the margarine of the fat by free acid, 
and are usually products of decomposition. They are found in gangrene, 
and are apt to take up coloring matter. Margarie acid (Fig. 57) crystallizes 
iu minute tufts, composed of very small and much-curved crystals. 

(c.) Choksterin occurs in flat tubular crystals or laminated plates (a) 
(Fig. 58), representing rhombic planes. It also occurs in the form ot granules 
of fat. It almost always occurs with other fats, and often in great abun- 
dance. It is always present in bile ; and colorless gall-stones consist almost 
entirely of this substance. It is also found iu the atheroma of arteries; in 
the serous fluid of ovarian and other serous cysts ; in the fluid of old hydro- 
celes. In general terms it may be stated that wherever tissues are in a state 
of fatty degeneration, there cholesterin may be found as the p)roduct of 
decomposition of their elements. Thus cholesterin is found in exudations, 





l-'rG. 57. — Margarie acid (Beale). 

Fig. HH.—Cfioleslerin plates— (a.) Regularly laminated, and viewed obliquely; at +, in the middle soli- 
tary plate, one edge is truncated ; (p.) Irregularly laminated, partially injured forms ; X 300 diameters 
(after Wedl). 

tuliercle, stratiform coagula in the inner coats of arteries, epithelial cells of 
the air-passages, in bronchitis (Beale), epithelium and oil-globules in 
coats of uriniferous tubes in fatty degeneration of the kidneys. It may be 
extracted froni many tissues in health, — e. g., crystalline lens of the eye 
(Beale). It is non-saponifiable, and is colored dark red by the action of 
sulphuric acid. 

These crystalline fatty concretions are frequently found in morbid growths, 
such ^s lipoma, and very commonly in various fluids and solids of the body. 

3. Pigment Concretions from blood, urine, or bile, assume the following 
forms : 

(a.) Black, brown, russet-yellow molecular granules, often adherent to micro- 
scopic crystals of ammonio-pJiosphate of magnesia. 

(b.) Bile-pigment, as a finely granular precipitate of a yellow-brown color, 
insoluble in water and in most acid.s — soluble in a boiling potash solution, 
with a greenish-brown tint. Nitric acid destroys, it, after causing it to pass 
through phases, first, of green, then of blue, and lastly of red coloration. 

4. Concretions of Uric Acid and Urates, simply or in the following combi- 
nations : 



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CONCRETIONS OF LIME SALTS. 



231 



(«.) Uric Acid. — The fundamental type of this crystal (Fig. 59) is the rhom- 
boid prism — often cut down to a rhombic jjlane. Frequently the crystals are 



Fig. 59, 



Fio. 60. 
a 





Fig. 59. — Onjstah of uric acid. — (o.) Rhomboidal truncated, hexahedral, and laminated crystals, (ft.) 
Rhombic prism ; horizontally truncated angles of the rhombic prism ; imperfect rhombic prisms ; on the 
last crystal in this row is seated a group of rectangular crystals, (c.) Prism, with a hexahedral Iiasic sur- 
face — barrel-shaped figure ; prism, with a hexahedral basal surface, (rf.) Cylindrical figure ; stellate and 
superimposed groups of crystals : X SOU diameters (Wedl). 

Fig. 60. — {a.) Urate of ammonia in the form of globules; ib.) Urate of amtnonia as an orange-yellow, fine, 
sandy concretion in the tubes of the kidney of a child, forming divergent, hard, irregular, black streaks, 
with lateral branches and twigs imbedded in the tubular substance : X GO diameters ; (c.) Angular mole- 
cules of urate of ammonia, aggregated into black concretions. 

seen grouped into concretions as rosettes, and are difficult of solution in water. 
They are insoluble in acids, alcohol, and ether. Potash causes their gradual 
solution, and they are generally .soluble in alkaline fluids. It occurs : 

(1.) As a sediment in the urine. 

(2.) As concretions of minute crystalline grains, of a gritty feel, but indis- 
tinctly visible. Such concretions are commonly known as " gravel." 

(3.) As amorphous or crystalline concretions, from a size clearly visible to 
a very large size, when they are named " calculi." 

(b.) Urate of Ammonia ( Fig. 60 j occurs as a finely-granular precipitate, 
colored of a clingy yellow, yellow-red, russet or rose-tint. It also occurs in 
the form of globules. It is difficult of solution in cold water ; less so in hot. 
Acids will separate the uric acid, which, under the microscope, will be seen 
to assume their characteristic form, as shown in the previous figure. 

5. Concretions of Lime Salts are composed of the following forms : 

(a.) Bmic Phosphate of Lime occurring as a gelatinous granular mass, solu- 
ble in acids, both in fluids and in solidified formations ; a soluble combination 
of protein substances with gluten, out of which it separates, especially in putre- 
factions and ossifications, in the form of molecules. 

(b.) Carbonate of Lime in a granular deposit in cell incrustation or stratifi- 
cation, either alone or in combination with the former. It is soluble in acid?) 
with effervescence. 

(c.) O.mlate of Litne occurs in octahedral crystals, sometimes remarkably 
minute. They are insoluble in water, alcohol, ether, and acetic acid ; b at 
soluble in hydrochloric acid. They are found in urine and in the urinary 
bladder (Fig. 61). 

6. Goncretiom of Ammonio-phosphate of Mar/nesia are composed of cryst.lLs 



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232 



TOPICS RELATIVE TO PATHOLOGY. 



of various shapes (Fig. 62). When rapidly formed, they cluster together in 
stellate groups, of needle-shaped crystals, or represent denticulate leaf-like 
forms. When slowly developed, they constitute trilateral prisms, in which 
both angles, corresponding to the same lateral edge, are truncated. These 
crystals are readily soluble in acids, even acetic acid. Wherever a develop- 
ment of ammonia takes place, the wide dissemination of phosphate of mag- 
nesia determines the formation of the insoluble triple phosphate. 

Fig. 61. Fig. 62. 



- L 




1 • ' 



■' L> 



Fig. 61. — (a.) Quadratoctahedrals of oxalate of lime ; (ft.) The basal plane of an octahedron forming a 
rectangle ; (c.) Compound forms ; (rf.) Imperfect forms (dumb-bell cryatals) : X 300 diameters (Wedl). 

Fig. 62. — The more usual forms of triple phosphate of magnesia and ammonia ; various metamorphic, 
hemihedral forms of the fundamental figure — the rhombic vertical prism : X 300 diameters (Wedl). 

In the formation of calculi and concretions these elementary constituents 
are classed by Rokitansky under two series, namely : 

(1.) Those made up essentially oi protein substances ; or into such as consist 
of gluten and fat, with the phosphates and carbonates of lime and magnesia. 

In this series are included the following : 

(a.) Protein concretio'ivi, as coagula within bloodvessels (vegetations); free 
bodies in serous cavities. 

(b.) Gluten-like colloid substances, commonly encysted, or eonified concre- 
tions, as the valve-vegetation of the heart. 

(c.) Fat, as in the contents of fattj^ cysts, or accumulations of fat in serous 
cavities, or in combination with — 

(d.) Bone-earth concretions, as in cretification and ossification of fibroid 
and cartilaginous textures (see "Mineral Degeneration," p. 126, ante). 

(2.) Into such as have a more varied composition, and are especially 
marked by the specific substances which they contain, e. g., bile, urine, &c. 

In this second series of concretions there are two varieties : 

(a.) Genuine stony concretions or calculi, which when diminutive, are termed 
"gravel" or "sand," resulting from the precipitation of one or of several of the 
specifio components of a secretion, the animal matter entering into their compo- 
sition as a bond of union or cement. The size of such calculi are extremely 
varied, from a fine but just perceptible sand-grain to that of a concretion fill- 
ing up the largest secretory canals and reservoirs. The smaller are usually 
spherical ; the larger have their shape in some measure determined by the 
form of the canals or reservoirs in which they occur — as, for example, gall- 
titones in the bile-ducts, and calculi in the urinary bladder. 

Where many concretions coexist, they acquire more or less smooth facets 
from reciprocal pressure and friction — as, for example, numerous calculi in 
tie gall-bladder or in the urinary bladder. 

The consistence and specific weight of calculi depend on their composition. 
They may be free in a cavity, or firmly impacted, or glued to a surface by 
the medium of a fibrinous exudation. 



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DEFINITION AND PATHOLOGY OF MALFORMATIONS. 233 

In structure they are extremely varied. A nucleus is sometimes recogniza- 
ble, composed of an amorpho-granular precipitate, round which concentric 
strata or crystalline formations form ; or they may be altogether crystalline, 
as the lithic acid calculus, or of cholesterin, as the white gall-stones. Some- 
times a foreign body may form a nucleus, introduced from without, as into 
the urinary bladder ; or a coagulum of blood or fibrin, or inspissated bile, or 
bile-pigment, to a cholesterin calculus in the gall-bladder. Examples of such 
calculus formations will be found described in calculi of the urinary bladder, 
salivary calculi, calculi of the lachrymal sac, prostatic calculi, gall-stones, 
and intestinal concretions. 

(6.) Inspissation and desiccation of some fluid of secretion. The ingredients 
of the secretion form the substance of concretion or calculus, including a con- 
siderable amount of animal matter, combined with the specific elements of 
secretion. In proportion to the inspissation is the hardness of the concretions. 
Cyst-like dilatation of follicles gives space for such concretions to accumulate ; 
for example, the follicles of the skin, mucous follicles, the tonsils, nasal and 
pharyngeal cavities, glands and prepuce, intestinal concretions, especially in 
divertipula of the intestines, inspissation of colloid or other cyst-contents. 

A microscopical analysis of concretions is essential for a determination of 
their source and character, and ought never to be omitted. (See Wedl, p. 
121, for an instructive illustration of this part, too long for quotation.) 

MALFORMATIONS. 

Latin Eq., Deformitas Ingenita ; French Eq., Vice de Conformation; German Eq., 
Missbildung ; Italian Eq., Vizio di Conformazione, 

Definition. — Deviatiotis from the normal development of the organism of the 
body occurring in the earlier period of gestation, or at least previously to the termi- 
nation of foetal existence. 

Pathology. — The imperfections consequent on such primitive malformations 
result in more or less permanent deformity, to which the harsh name of mon- 
strosity has been given ; and the doctrine of such congenital deformity is now 
comprehended under the scientific name of "Teratology" (Tipa<;, signifying 
monster).. The superstitions, absurd notions, and strange causes assigned to 
the occurrence of such malformations are now fast disappearing before the 
lucid expositions of those famous anatomists who have made the development 
and growth of the ovum a subject of special duty. It is sufficient to mention 
here the names of J. Muller, Rathke, Bischoff", St. Hilaire, Burdach, Allen 
Thomson, G. and W. Vrolik, Wolff", Meckel, Simpson, Rokitansky, and Von 
Ammon, as sufficient evidence that the truths of science will in time dispel 
the mists of ignorance and superstition. Nevertheless, much mystery still 
enshrouds the origin of malformations ; and opinions concerning the origin of 
them may be considered in the two main issues, namely, — (1.) Are they due 
to original malformation of the germ? (2.) Or, are they due to subsequent 
deformities of the embryo by causes operating on its development? 

With regard to the first issue, it is believed that the germ may be origin- 
ally malformed or defective, owing to some influence proceeding either from 
the female or from the male ; as in the case of the repeated procreation of the 
same hind of malformation by the same parents, deformities on either side being 
transmitted as an inheritance. Farther evidence of original germ-defect is 
held to exist in the hereditary deformities extending over more than one 
generation ; such, for example, as harelip, excessive number of fingers, hypo- 
spadias, and the like. 

With regard to the second issue, namely, whether subsequent deformation 
may not follow an originally well-formed germ, it has been said, — 

(1.) That such deformation may be produced by mental impressions on 
pregnant women ; but of this there is an absence of positive proof. 

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234 ■ TOPICS RELATIVE TO PATHOLOGY. 

(2.) It has been proved that external injury, suffered by women during 
pregnancy, will bring about deformation, as in the congenital deformity of 
hydrops ventrieulorum cerebri. 

(3.) The late Sir James Simpson has shown how diseases of the ovum and 
foetus will bring about deformation of the child. The diseases are chiefly acute 
and chronic inflammation of the placenta, attachment of pseudo-membranes 
to the foetus, and adhesions of the foetus to the placenta. Self-amputations 
are thus also explained. Moles, mother's marks, and cutaneous spots, are 
ascribed to morbid states of the coats of the ovum. 

(4.) A very generally recognized cause of malformation consists in im- 
peded development of the foetus, the cause of which is not always obvious, 
but is for the most part concealed. The impediment may be confined to one 
part or extended to many, to more than one region of the body, for example, 
and to more than one apparatus. 

To understand the results of impeded development, the student requires to 
know the natural forms through which the several parts of the foetus pass in 
their normal development to completeness. If he does not know these, he 
cannot appreciate an "arrest of development" where it ceases at a cert.ain 
point, and advances no farther. The increased growth and progressive nutri- 
tion of the normal portions of the body also impart important modifications 
to the final result. Transient forms of the human foetus are comparable to 
persistent forms of many lower animals ; hence, malformations resulting from 
arrest of development often acquire an animal-like appearance. Many are 
unfit for life after birth. 

The following elementary facts in "teratology" are essential to a proper 
understanding of malformations : 

1. Dissimilar parts are never fused or united ; only parts that are not origin- 
ally dissimilar, but which are developed from a common mass. 

2. Malformed parts are restricted to their determinate place. 

3. No malformed organ ever loses entirely its own character, nor a mal- 
formed animal its generic distinction — a distinct gradation and natural order 
are observable throughout. Thus, there are different degrees of malformation 
in the same deformity, varying from the greatest possible degree to the very 
least. 

4. Deformities do not take place by chance, and double deformities are 
always of the same sex. 

No suitable classification of deformities can yet be given ; but taking embryo- 
genesis as a basis, a grouping may be made, useful alike for physiological and 
medical practice. Such is that originally given by F. A. Von Ammon and 
W. Vrolik. The same principle seems to have guided the College of Physi- 
cians in the following grouping of malformations (p. 237, Appendix to Nomenr 
cloture o/ Diseases') : 

I. — Malfoemations resulting from Incomplete Development oe 
Growth of Parts. 

(a.) op the body generally. 

Head absent, or rudimentary. (Nine types are described by Vrolik.) 

Cranium defective. 

Lower jaw absent or defective. 

Upper and lower extremities absent. 

Lower extremities absent. 

One lower extremity absent. 

Hands and feet articulated to scapulae and pelvis 

Fingers and toes deficient in number. 



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early periods 
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CLASSIFICATION OF DEFORMITIES. 235 



(6.) OF THE NERVOUS SYSTEM. 

Brain absent, with exposure of base of skull. 

Brain rudimentary or incompletely developed — several types, accord- 
ing to incompleteness. 

Spinal cord absent or imperfect, witb more or less exposure of spinal 
canal. 

Continuity of nerves -witli nerve-centres incomplete. 

(e.) OF THE ORGANS OF SPECIAL SENSE. 

Eyes absent. 

Eyes imperfect. 

Eyelids incomplete. Eyelids remaining united. (Symblepharon.) 

External ear absent. Pinna adherent. 

Meatus externus closed. 

Internal ear imperfect. 

Nose absent. 

Nose imperfect. 

Nose resembling a proboscis. 

(d.) OF THE VASCULAR SYSTEM. 

Heart absent. 

Cavities of heart deficient in number. 

a. One auricle and one ventricle. 

b. Two auricles and one ventricle. 
Septa incomplete. 

a. Auricular. 

b. Ventricular. 

Orifices obstructed or imperfect. 

a. Right auriculo-ventricular aperture. 

b. Pulmonic aperture. 

c. Left auriculo-ventricular aperture. 

d. Aortic aperture. 

Foramen ovale prematurely closed. 

Ductus arteriosus prematurely closed. 

Origins of aorta and pulmonary artery transferred. 

Origin of ascending aorta from left ventricle, and of descending aorta 

from right ventricle, through the ductus arteriosus. 
Commencement of descending aorta contracted or obliterated. 
Foramen ovale persistent. 
Ductus arteriosus pervious. 
Cardiac valves imperfect. 
Pericardium absent. 

(e.) OF THE RESPIRATORY SYSTEM. 

Lung (one or both) absent. 
Pulmonary lobes deficient in number. 
Larynx and trachea absent or imperfect. 

(/.) OF THE DIGESTIVE SYSTEM. 

(Esophagus impervious. 

Intestine impervious, or deficient in various regions. 

Anus impervious. 

Anus in unusual situations. 

Liver preternaturally small. 

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236 TOPICS RELATIVE TO PATHOLOGY. 

Gall-bladder absent. 

Biliary ducts impervious. 

Uracbus patent. Vitelline duct patent. 

(ff.') OF THE URINARY SYSTEM. 



Kidney (one or botb) absent. 
Kidney lobulated. 



Ureters absent or impervious. 
Uracbus persistent. 



(h.) OF THE MALE ORGANS OF GENERATION. 

Penis diminutive, resembling clitoris. 
Prepuce abbreviated — elongated. 
Testicle (one or both) absent. 
External organs absent. 

(i.) OF THE FEMALE ORGANS OF GENERATION. 



Ovary (one or botb) absent. 
Uterus absent. 
Vagina absent. 
Vagina impervious. 



Vagiila a cul-de-sac. 
External organs absent. 
[Hymen imperforate.] 



II. — ^Malformations resulting from Incomplete Coalescence of the 
Lateral Halves of Parts which should become Conjoined. 

(a.) on the anterior median plane. 

Fissure of the face. 

" " iris. Coloboma. 
" lip. 

a. Single harelip. 

b. Double harelip. 
" " palate. 

a. Hard palate. 

b. Soft palate. 

" " nose. Naso-buccal fissure. 

" " sternum. 

" " diaphragm. 

" " abdominal walls. 

" " pubic symphysis. 

" " anterior wall of urinary bladder (with extroversion of 
the posterior half). 
Epispadic fissure of the urethra. 
Hypospadic fissure of the urethra. 
Fissure of the scrotum. 

(b.) on the posterior median plane. 

Fissure of the skull. 

" " spinal column. Spina bifida. 

a. Complete. 

b. Partial. 

1. Cervical region. 

2. Lumbar " 

3. Sacral 
Fissure of the spinal cord. 



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CLASSIFICATION OF DEFORMITIES. 237 

IIL-MaLFORMATION RESULTING FROM COALESCENCE OF THE LATERAL 

±1ALVES OF Farts which should remain Distinct. 

Lower extremities conjoined. Syreniform foetus 
Fingers or toes conjoined. Coalescence— webs 
Monoculus. Cyclops. 
Double kidney. 

IV.— Malformations resulting prom the Extension of a Commis- 
sure BETWEEN THE LATERAL HALVES OP PaRTS (CAUSING AP- 
PARENT Duplication). ^ 

Double uterus. 
Double vagina. 

V.-Malformations resulting from Eepetition or Duplication of 
Parts in a Single Fcetus. 

Supernumerary fingers and toes, 
cavities to heart, 
valves. 

VI.— Malformations resulting prom the Coalescence of two Fe- 
tuses, or of their Parts. xwo j^ce 

DoubL fetus""" ^^'' ■'''''*°*' ''°'^^'*''*^^g ^ ^^"^"^ covered by integument. 
a. One perfect. The other an appendage. 
0. Both more or less perfect. 

1. The middle parts united. The upper and lower distinct. 

I. Ihe upper parts umted. The lower distinct. 

6. The lower parts united. The upper distinct. 

VIL-CONGENITAL DISPLACEMENTS AND UnUSUAL POSITIONS OF PaRTS 

of the Fcetus. , -lAitia 

Transposition of yhcera.-[Influence of fcetus as always developed 

lymg on left side, as a rule, to be considered here 1 
Merma or ectopia of the bram. 
" heart. 
" " " lungs. 

" " intestines. 

Varieties : 

Through diaphragm. Syn., Diaphragmatic hernia. 

ihrough abdominal walls. Syn., Abdominal hernia 

Ihrough umbilicus. Syn., Umbilical hernia 
i-xtroversion of posterior wall of bladder. 
Testis retained in abdomen. 

" inguinal canal. 



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238 



TOPICS RELATIVE TO PATHOLOGY. 



In the case even of double or duplex deformities only one germ seems to^ be 
concerned. In illustration of this, Dr. Allen Thomson has given the following 
demonstrations (Figs. 63 and 64). He has shown that on one yolk, and on 
one germinal membrane or blastodermic vesicle, two primitive grooves may be 



Fig. 6.5. 








Fir, 63.— From a fowl's egg, after sixteen or eighteen liours' incubation, magnified four times, {a.) The 
germinal area of the cicatrieula; (h.) The transparent area, containing two primitive traces of embryos; 
(c, c.) Primitive grooves of the double embryonic trace, on each side of which are seen the laminje dor- 
sales (after A. Thomson). 

Fig. 64. — Double embryo removed from a goose's e^^^, after five days' incubation, magnified four times, 
ig.) The common heart; (A.) Kndiments of the superior ; (i.) Of the inferior extremities; (A.) Thecom- 
liion cephalic luld of the amnios ; {I.) The common folds (after A. Thomson). 

formed, which, in their ulterior development, shall probably (certainly, if they 
live ?) form a double monster, as maj^ be seen in Fig. 64, taken from a goose's 
egg after five days' incubation. The formation of such a primitive groove in a 
single ovum is sufficient to explain the origin of the principal types of double 
monsters. Such malformations of the ovum have been overlooked by the Col- 
lege of Physicians, and are omitted in the table just quoted. 

These are the earliest examples of double deformity that have ever been 
recorded ; and no student of Medicine should remain ignorant of them. 



FUNCTIONAL DISEASES. 

Latin Eq., Vilin Naturnrnini Aeliomim. ; French 'S.q,., Maladies Fvnciionelles ; Gbr- 
MAN Eq , Fiinctionelle KravkheUen oder AJf'cctionar j Italian Eq , Malattie di 
Funzlone. 

Definition. — All those diseases in. which the concurrent living action of the 
parts or organs (i. e., the concnrTent exercise of function^ is not maintained, or 
in which the contractility, tonicity, nutrition, secretion, sensation, or motion of 
parts may be increased, diminished, or perverted, and that without fever or inflam- 
mation. 

Pathology — Hitherto the complex morbid processes which have been 
described embrace nearly all the important forms of disease which affect the 
various organs which the eye can appreciate, assisted or not by the micro- 
scope, or which can be appreciated by other physical aids, such as by chemical 
analysis or reagents ; all of which are now comprehended in the science of 
morhid anatomy, and demonstrated by anatomical investigations. Morbid 
changes which are not visible, or which are not yet ascertained by any physi- 
cal means of observation, are described as functioned or dynamic. They em- 



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PATHOLOGY OF FUNCTIONAL DISEASES. 239 

brace all those_ diseases in which the action, the secretion, or the sensation of 
a part is impaired, without any primary alteration of structure of the organ 
or tissue affected, so far as our imperfect means of research can ascertain. It 
is possible, however, as physical aids to the senses increase and become more 
practical, thereby improving the means of observation, that the now so-called 
functional changes may eventually be shown to depend upon some concomi- 
tant anatomical change or alteration of structure (molecular it may be), which 
at present is not appreciable. The appreciable morbid forms of disease which 
have been described, and which are either permanent or more or less persistent 
after they are formed, are described in the science of morbid anatomy as lesions. 
They are common to a greater or less number of individual diseases, hereafter 
to be considered and described in this Text-book of the Practice of Medicine. 

It will then be seen that such lesions do not essentially constitute the disease, 
but are rather the results of disease, and are serious or otherwise according to 
their nature, their site, and the amount of the structural change involved. It 
is the duty of the pathologist and the physician to connect them with signs 
and symptoms of disease, with the object of adopting remedial measures for 
their prevention, or cure, or for the relief of such inconveniences as they may 
cause. 

But the class of complex morbid states, known as "functional," are often 
notless strikingly formidable in their symptoms than those attended with 
obvious lesions ; they are, in many instances, the cause of much suffering. 
They are_ usually, also, of long duration, without fever, generally difficult of 
cure, having a strong tendency to recur, and to terminate eventually in organic 
changes capable of demonstration. 

The occasional exciting causes of such diseases act upon the vital functions, 
or the usual manifestations of life and action in the various organs and struc- 
tures._ They will be considered in detail under the various organs whose 
functions are thus specially implicated. They have hitherto been described 
under the name of " JSTeuroses;" but, year by year, as a knowledge of morbid 
anatomy has extended, the number of these functional diseases has diminished. 
They were so named because " functional " diseases were believed to have 
their origin in the nervous system, and were indicated by disordered sensa- 
tion, volition, or mental manifestation, without any evident lesion in the struc- 
ture- of the part, and without any material agent producing them. Broussais 
attributed them to a state of irritation of the brain and spinal marrow. In 
the Nomenclature of the College of Physicians of London, the functional 
diseases of the nervoiis system constitute a group which embraces all affec- 
tions, of which the cause is either undefined or variable, whether its probable 
seat be the brain, the cord, or the nerves. Its components are so far hetero- 
geneous as to include such discordant elements as hydrophobia, epilepsy, 
neuralgia, tetanus, cramps, chorea, shaking palsy, hysteria, catalepsy, trance, 
and hypochondriasis. 

At present the following are functional diseases, which, comprehended under 
" Neuroses," are of unknown anatomical origin : 

Functional diseases of the heart ; of the nervous system, such as chorea, 
tetanus, epilepsy, acute epilepsy of infants and children, hysteria, catalepsy, 
hypochondriasis; while colic, vomiting, diarrhoea, constipation, have been 
regarded as " neuroses," or functional diseases of the alimentary canal. 

But when it is remembered that every function of the animal body consists 
of one or more, sometimes of several individual but concurrent and successive 
actions (actiones) ; that each action is performed by one or more organs con- 
structed for the pui-pose ; that each organ consists of certain elementary tissues, 
arranged in a certain form ; that each elementary tissue not only possesses a 
definite arrangement of its minute particles or constituent atoms, but is en- 
dowed with certain physical and vital or physiological properties (facultates'), 
by virtue of which it is enabled, with its particular arrangement and the me- 

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240 TOPICS RELATIVE TO PATHOLOGY. 

chanical form in which it is disposed, to concur in the accomplishment of the 
actions assigned to it; then, every derangement of function (i. e., every fime- 
tional disease) depends on the derangement of some of its constituent actions. 
But it is doubtful how far any action can be deranged without some change 
in the properties of the elementary tissue of the organ; and it is still to be 
determined to what extent these properties can be impaired, disordered, or 
annihilated, without some corresponding change in the elementary atoms 
which constitute the intimate structure of the organ (Ceaigie). At present, 
the pathological explanation of these so-called functional diseases is, to a very 
great extent, a matter of theory merely. 

Of the morbid states named at p. 66 as elementary forms of _ disease, there 
remains to be considered one very complex condition, implying variations 
of fiinctional tension to an extreme extent, and which will be found to take 
part in the expression of many diseases, both local and general: namely,— 



FEVEE. 
Latin Eq., J'eJris; Frknch Eq., i?'iS»?-e; German Eq., i^'ieJer; Italian Eq., J'eftST-e. 

Definition A complex morbid state which accompanies many diseases as part 

of their phenomena, more or less constantly and with a defined regularity, but va- 
riously modified by ilie specific nature of the disease which it accompanies. It 
essentially consists in elevation of temperature, which must arise from an increased 
tissue-change, and have its immediate cause in alterations of the nervous system 
(ViECHOW, Paekes). 

Pathology. — In describing the nature of fever, the following statements are 
principally compiled from the Gulstonian Lectures of Dr. Parkes, delivered 
before the College of Physicians in 1855, and from a review by Dr. Jenner, 
" On the Proximate Cause of Fever,." in The British and Foreign Medico- 
Chirurgical Review for 1856. Knowing how difficult it is to convey an ortho- 
dox account of the nature of fever ; fully impressed with the great importance 
of the subject ; and believing " that so consistent a theory of the nature of 
fever, and one so largely supported by facts, has not been placed before the 
profession as that developed by Dr. Parkes, I only hope I may be able to do 
it justice in the attempt to lay it before the student of Medicine in the follow- 
ing form. In the eloquent language of Dr. Parkes, ' I shall have to allude 
to inexplicable phenomena, to vast spaces still unfilled by solid facts, to spots 
unknown to observation, and to regions lighted only by the dim and treacher- 
ous ray of speculation.' " , 

The practical object aimed at in the exposition about to be given, is to fix 
the scientific principles which ought to guide clinical investigation in determi- 
ning, the Natural History of fevees generally ; and especially the scientific . 
principles which must define the differences which subsist among specific fevers ; 
and so aid in determining the conditions under which they are generated or 
propagated — their development, course, or progress, and their defervescence. 

" A hot skin, a quick pulse, intense thirst, scanty and high-colored urine," 
are phenomena common to ipany diseases ; and when they are present it is said 
that the patient is feverish, or that he suffers from fever or pyrexia. There are 
some diseases in which such symptoms constitute the prominent, and almost ■ 
the only appreciable phenomena, and which run a more or less definite course, 
without the necessary development of any constant local lesion. Such diseases 
have been emphatically termed " fevers," or sometimes specific, primary, or 
idiopathic fevers. When diseases marked by local lesions — such, for instance, 
as the local inflammations — are attended by the symptoms just stated, then 
the pyrexia, fever, or feverish symptoms which attend them, are said to be 
secondary or symptomatic ; and the physician is accustomed, when he deals 

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NATURE OF FEVER. 241 

with such cases, to abstract the symptoms of fever from the other symptoms 
proper to the special affection. In other words, he prescribes for, and tries to 
cure the special affection, and not the fever, because he knows that when he 
has subdued the local disease the femer will subside. Not so, however, with 
the fever of specific diseases like small-pox, typhus, or enteric fever. The physi- 
cian cannot cure such a fever ; but he may guide its course, by judicious 
management, as an experienced pilot may guide a ship and preserve it through 
a storm ; and this is true of all specific fevers. 

It is to the nature of fever (whether primary and specific, or secondary and 
symptomatic), considered in its abstract relations, that the attention of the 
student is here directed, and not to any particular fever, such as ague, typhus 
fever, traumatic fever, or the like. 

It is to fever in general, or in the abstract, that the following observations 
apply. It is to the pyrexial symptoms which are common to many diseases 
(such as to smallpox, scarlatina, measles, typhus, ague, pneumonia, nephritis, 
meningitis), and which, " like shadows to substance, are necessary to the very 
existence of such diseases, but yet are not, per se, any one of these diseases," 
tha,t the following description refers. 

Galen defined fever as a preternatural heat — "Calor prceter naturam." 
Subsequently many other additional clauses were added to this definition, 
such as a " quick pulse," " turbid urine," and the like ; but still, the improved 
definition would not meet the requirements of every case ; and now it is fully 
recognized that of all the clauses and phrases in the usual definitions of fever, 
"preternatural heat" is the- only one whose accuracy is unimpeachable. In 
all cases, therefore, where fever is present, there are two points to be deter- 
mined ; namely,- — (1.) The amount of the preternatural heat determined by ac- 
curate measurement ; (2.) The amount of the tissue-change, as represented by 
an estimation of the amount of all the excreta relative to the body weight. 

It is the exact sequence of phenomena we desire to know in every case 
where pyrexia is present, as well as the meaning and correlation of the phe- 
nomena : and symptoms sufiiciently characteristic usually become developed 
and superadded to the febrile phenomena, by which the physician is able to 
define the specific nature of the disease or fever as a whole, and to say of this 
case or of that, " It is an enteric fever," or " It is an ague," or " It is a rheu- 
matic fever," or " a, pneumonia," or "a dysentery," or any other form of illness 
where pyrexia is present, which we are able clinically to recognize. It is not 
very long since we were able to do this. Up till within a comparatively short 
time ago the classification and diagnosis of " Fevers" was not such as to dis- 
tinguish and separate their varied forms and varieties from each other. 
" Common continued fever," for example, was a comprehensive name which 
included many very different types of fever ; and no means of observation 
have been of late so exactly discriminating, so as to distinguish one form of 
disease from another where fever coexists, as accurate observations on the 
temperature of the patient, determined by the thermometer. In acknowledg- 
ing this great fact, it is important to observe that the absence of such exact 
observation, and the trusting to general signs alone, have hitherto led to great 
confiision — a confusion which has been unfortunately increased by a pernicious 
system^becoming too common — of naming " Fevers " from the place or 
locality where supposed varieties of fever have prevailed as epidemics ; or by 
the use of local or provincial native names. For example, the Walcheren 
Fever, Levant Fever, Mediterranean Fever, Crimean Fever, Bulam Fever, 
African Fever, Fernando Po Fever, Lisbon Fever, Bengal Fever, Pucca 
Fever, Gall-sickness of the Netherlands, Hong Kong Fever, and other names 
not less barbarous, may be quoted. Except as matter of history, and as bea- 
cons to warn us from a great danger to science, let these and such-like names 
be consigned to oblivion. With the exact means at the disposal of the physi- 
cian as aids to diagnosis (and which are about to be described), every variety 

VOL. I. 16 

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242 TOPICS KELATIVE TO PATHOLOfiT. 

of illness where fever takes a part may be accurately distinguislied, its t3rpe 
recognized, and its place fixed in nosology ; or, if it should be anomalous^ its 
exact departure from the type may be not less accurately defined and described. 
The phenomena which thus call for special investigation are those which 
are strictly related to the development and progress of the febrile state. 
They ought to be determined by clinical observation in all case? of disease 
where fever may be present. The facts to be ascertained are not less sig- 
nificant of the abatement, subsidence, or "defervescence" of the febrile state 
than of the advent of local lesions. The term " defervescence," in fever, is a 
comparatively new one in English pathology. It was first used by Professor 
Wunderlich, and subsequently adopted in this country by Dr. Parkes. It 
signifies the period during which the temperature of the fevered body is de- 
clining to its normal amount from that intense degree of heat attained m the 
state of accession of the febrile phenomena. This "defervescence" may be 
sudden, when it is regarded as a "crisis;" or it may be gradual, and is then 
described as a "lysis" — the "insensible resolution" of the older authors; or it 
may be partly sudden and then slow, when it may be described as "wave-like," 
with gradual and sometimes regular alternations of high and low temperature, 
as Dr. Parkes was the first to point out ( The Composition of the Urine in 
Health and Disease, p. 270). 



The Usefulness of the Thermometer at the Bedside in the Diagnosis of Pyrexia. 

One hundred and seventeen years ago (1754), Antonius de Haen (the first 
teacher of clinical medicine in the Hospital of Vienna) impressed his pupils 
with the necessity of attending to the temperature of the body in disease, as 
measured by a thermometer, instead of being estimated merely by the sensation 
of heat imparted to the hand laid on the skin of the patient. He showed 
that even in the cold stage of ague, with the teeth chattering and the body 
shivering, the temperature of the blood is rapidly rising, although the pallid 
skin may really be colder than usual — its supply of blood being diminished 
by the contraction of the bloodvessels. He first demonstrated with measured 
accuracy how much the heat of the blood, and therefore of the body, is aug- 
mented under the influence of the febrile state ; and when the crude appli- 
ances and the rough instruments of a hundred years ago are compared with 
the delicacy and refinements of "the instruments of precision" of the present 
day, it may be of interest now to observe how the progress of knowledge and the 
powers of modern research have not suffered the valuable pathological lessons 
to be lost sight of which are to be learned from the clinical use of the ther- 
mometer, as De Haen taught a hundred and seventeen years ago. When the 
hand of the physician alone is used to judge of the temperature of a patient, 
or when the feelings of the patient are alone taken as a measure of his tem- 
perature, it can easily be understood how such kinds of observation are 
extremely fallacious, doubtful, and unsatisfactory. The determination of the 
amount of heat in fever cases is stamped by a much more early appreciation 
of its importance and value than even since the time of De Haen ; for, ever 
since the days of Hippocrates, the physician and the surgeon have been in the 
habit of applying the hand to the skin of the patient, to appreciate the pres- 
ence of abnormal heat. But the practical application of the thermometer in 
place of the hand, while it is obviously a more accurate method, has never 
come into general use, mainly on account of the difficulty of getting instru- 
ments^ sufficiently sensitive and trustworthy — instruments, in fact, of sufficient 
precision. The time and trouble required to work with crude and inefficient 
instruments soon brought them into disuse and discredit; but now the in- 
struments required may be obtained so delicate and accurate, and the time 
taken to apply them is so insignificant, that the student of medicine and the 

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METHODS FOR RECORDING THE FEVER -HEAT OF THE BODY. 243 

n Kr? r ? °° 5^^?®- ^°'' ^eglecting to use them. When it is remembered 
also, that Galen's definition of fever is still the one whose accuracy remaS 
not only unimpeachable, but fully demonstrated and recognized; thatTt de^ 
scribes fever to consist in " a preternatural heat,"^it is obviously e sential that 
we should be able to measure this heat, and so learn the significance of such 
increase of temperature m every case of disease where fever may be present 
The careful physician counts the puke and the respirations in all cases of Al- 
ness; It IS not less incumbent on him to measure the amount of heat. By 
means of a delicate thermometer he has in every case of fever an accurate meas 
urerof Its amoun ; and the student of medicine, as one of the earliest clS 
lessons m hospital wards, should be taught to look to the excreta, and o the 
various physiological conditions of the patient, for the products of the meta! 
morphosis of tissue equivalent to the amount of heat in each disease 

Ji.ver since the publication of the second edition of this work when the 
thermometer as a means of measuring the heat in cases of fever wLs first ex! 

tCi ortancJ o? he°fh '°' ^''^'r*^' ' ^^"-^ ^^^'^ ^^^^l^ P^--*^ t° -" th^t 
the importance of the thermometer, as an instrument in the diagnosis and 

prognosis of disease, has become more and more apparent. There is ample evi^ 
dence of this m the contributions to the literature of this subject from t\7pe^^^^^^^^ 

M fie ' oX p'' T*°°' ^'^f'^y'"^.' C°™eli^i« Fox, Grimshaw, Mackgan, 
Millei, Ogle, Perry, Prior, Sidney Einger, Stevenson Smith, Reginald E 
Thompson, and othere, since the second edition of this text-book Lpeared' 
The thermometer is now as much of a necessity and as much of a companion 
to the medical man as the stethoscope. ptuwu 

t J^' tlie^om^try of disease is thus practically shown to be important from 
two points of view, inasmuch as,-(l.) The continuous daily «se of the ther- 
mometer greatly fanhtates the clinical recognition of diseases; and iids us in 
acquiring an accurate knowledge of various diseases. It aids the busv practi- 
tioner m coming to more certain and safe conclusions than heretofore; and so 
relieves him of much anxiety of mind in doubtful cases. (2.) The use of the 
tfuirmometer tends to elucidate the course, tendencies, and results-in short Tn^ 
JNATUEAL History— o/ all diseases where fever is present 
heads^- P'"°P°®®*^' ^lierefore, to illustrate this subject under the following four 

.7, ^■J^'I'^f^'-'^^fs^ Methods, and Practical Rules for Observing and Recordinq 
the fempm-ature of the Human Body in Diseases where Fever may he present 
Animal heat has been determined in two ways— namely, either bv the ordi- 
nary mercurial thermometer, or by the thermo-electric apparatus. The latter 
may mdicate fractions of a degree, and in this respect surpasses the powers 
01 ttie most delicate mercurial thermometers. MM. Becquerel and Bresohet 
employed such an apparatus to determine the temperature of internal parts 
iHe apparatus consisted of two wires, of different metals, soldered together 
and having their free ends brought into communication with a thermo-electric 
multiplier having an index showing tenths of a degree. The fine points of 
tHe wires being passed through difierent parts of the body (like acupuncture 
needles) indicated the temperature of the tissues at the point of contact of 
me two metals. For example,— passing the wires an inch and a half into 
tiie calf of the leg, the temperature was found to be 98° Fahr., while at the 
depth of the third of an inch it was only 94° Fahr., showing some cooling of 
the body towards the surface compared with the interior. The superficial 
lascia of the biceps was nearly 3° Fahr. lower than the temperature of the 
muscle Itself But notwithstanding the greater delicacy of the thermo-electric 
apparatus, a sensitive mercurial thermometer, finely graduated and compared 
with a standard one, is the only instrument of practical usefulness, as yet, 

wl ^°^^ clinical purposes; and for obvious reasons. 

W hatever thermometer is used, it is necessary to compare it with a standard 
one, and note the diflTerences between every degree. A thermometer is bad, and 

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244 



TOPICS RELATIVE TO PATHOLOGY. 



all but useless, if the differences between various degrees are unequal ; but it 
is quite serviceable if the same sum is to be added or subtracted for each 

degree. The price of such an instrument need 
^"''■'''- Fig. 06. jjQ^ now render it difficult nor expensive for a 

A^~^ student to acquire a competent practical knowl- 

edge of " the thermometry of disease." 

It is necessary to have an instrument which 
will determine the temperature in the mouth, 
axillfe, rectum, or other parts of the body. Such 
an instrument is named a " clinical thermometer;" 
and it must be of unquestionable veracity. If the 
instrument is not absolutely accurate, its errors 
require to be known. Differences in the diameter 
of the bore (in calibration ), throughout the entire 
length of thermometer, seem to be almost una- 
voidable, as yet, in their manufacture. 

The majority of the instruments at present made 
seem to indicate a temperature sometimes higher 
and sometimes lower, at different parts of the scale, 
than is correct. For example, Dr. C. Fox quotes 
a certificate of verification from the Kew Obser- 
vatory of one in his possession, as follows : 



At .52° Pahr. + 0.1 
" 62° " —0,1 
" 72° " + 0.1 

That is to say, at 52^ Fahr. Jj must be added, at 
62^ Fahr. Jj requires to be subtracted; and again, 
at 72^, y'u must be added. As no two faces are 
alike, so no two thermometers seem to be alike. > 
Dr. Prior of Bedford, in comparing five instru- 
ments, one with another, found that "no two of 
them jjrecisely corresponded at any one time;" 
and, as Dr. C. Pox very justly observes, the want 
of complete agreement between the observations 
of physicians on temperature is doubtless partly 
due to the differences of the readings of the ther- 
mometers employed, and also to the fact that all 
observers do not take the temperature of the same 
parts of the body. Tlie rectum is about two- 
fifths of a degree of Fahr. warmer than the mouth ; 
and the mouth four-fifths of a degree warmer than 
the axilla or the groin (Fox), unless precautions 
are taken, as afterwards shown, to render the axilla 
a closed cavity. 

In meteorological observations, only those ther- 
mometers are employed which have been verified 
by means of a comparison with the standard 
instruments in the Greenwich or Kew Observato- 
ries. How much more important is it that clinical 
thermometers (where life or death may hang on 
the difi'erence of a degree) should be verified and 
certified to in the same way, so that the proper corrections may be made for 
errors which seem to be inevitable ? Although the accuracy of the instru- 
ment, or delicacy of it, may be guaranteed by the manufacturer, it cannot 
be depended on. Dr. Fox gives an illustration, among several, in which the 




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MODE OF USINa THE CLINICAL THERMOMETER. 245 

following results were returned in the certificate from the Kew Observatory, — 
namely, at 85°, -j% must be subtracted ; at 90°, -f% ; at 95°, j% ; at 100°, ^% ; and 
at 105°, y^ must be deducted — errors varying from fg to j\, or half a degree. 
The only safe rule, therefore, is, that each instrument ought to be sent to Kew 
for verification, to be returned to the owner with a certificate containing the 
corrections for its several readings, if any are requisite. A fee of half a crown 
is charged at Kew for this certificate of verification ; and if the makers would 
do this, and charge the fee to the price of the instrument, it would save a 
great deal of trouble.* 

A good clinical thermometer ought to have a uniform and correct scale, 
having a range from 90° to 112° Fahr., exhibiting also fifths Fahr. of degrees, 
and be one-fifth of an inch apart from each other. It ought to be a sensitive, 
mercurial maximum self-registering (Fig. 66) one (known as " Phillip's maxi- 
mum ") ; which does not require to be read in situ, but may be removed from 
contact with the part, and read when convenient. The bulb of mercury 
should be as thick as the diameter of the stem, and not more, so as to expose 
a sufficiently large surface to the part of the body whose temperature is to be 
determined. 

An Ordinary but very Sensitive Thermometer (Fig. 65), made with a curve, 
in order that its bulb may be the more easily and perfectly fitted into the 
axilla, while the stem, being carried upwards, renders the reading in situ 
more easy, is a useful instrument for teaching students to observe dn clinical 
classes ; but is less useful in general practice than the maximum self-register- 
ing instrument. 

Directions for Use. I. The Curved Thermometer (Fig. 65).— Its bulb must 
be well fitted into the arm-pit, being introduced below the fold of the skin 
covering the edge of the peotoralis major muscle, and so kept in close contact 
with the skin, completely covered and firmly surrounded by the soft parts. 
In very thin or very old persons this adjustment requires special care. The 
instrument must be retained in situ during a period of not less than four 
minutes ; and the height of the mercury in the graduated stem must be read 
while the thermometer is still undisturbed in the axilla, care being taken that 
the axis of vision falls perpendicularly on the column of mercury in the tube. 

II. The Straight Thermometer (Fig. 66), which is self-registering, m/ust have 
its index set before commencing to take an observation. 

]^N.B. — The Index is the bit of mercury detached from the column in the stem 

OF THE INSTRUMENT,] 

1. This index is to be set by bringing the bit of detached mercury down 
into the clear part of the stem, just below the lines which indicate the de- 
grees. This is done by taking the bulb and stem of the instrument firmly in 
the hand, and then by a single rapid swing of the arm the index will come 
down the stem ; and this swing of the arm must be repeated till the top of the 
index is at least below the lines which indicate the degrees. 

2. After the index has thus been set, the bulb of the instrument may then 
be applied to the axilla, or between tjie thighs, or any part which is com- 
pletely covered; and being retained in close apposition (by strapping, if 
necessary) with the surrounding soft parts for a sufficient length of time, the 
instrument is to be carefully and gently removed, when the top of the index 
— i. 6., the end farthest from the bulb — will denote the maodmum temperature 
during the period the instrument has been in perfect contact with the parts. 
The patient should have been at perfect rest in 'bed for at least one hour be- 

* Cassella of Hatton Garden, Hawksley of Blenheim Street, London, and Harvey 
and Reynolds of Leeds, are the most careful makers of clinical thermometers, in my 
experience. 

■ 

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246 



TOPICS KBLATIVE TO PATHOLOGT. 



fore observations on temperature are made, and he ought to lie on the side, so 
as to completely close the axillary space which is the seat of the thermometer, con- 
verting it into a close cavity. 

III. The Observations ought to be continuous daily, and regularly taken 
at 'the same hour every day, throughout the whole period of sickness. The 
most useful periods for observation are — (1.) Between 7 and 9 o'clock in the 
morning ; (2.) At noon ; (3.) Between 5 and 7 o'clock in the evening ; (4.) 
At midnight. For most practical purposes, it is sufficient to note the tem- 
perature twice daily, — morning and evening, with an occasional observation 
at midnight. 

IV. In all observations of temperature the pulse and the respirations 
should be noted at the same time. 

In less important cases, the physician may make at least one observation 
daily himself, and leave the others to the friends of the patient or the nurse, 
if either of them are sufficiently intelligent. This arrangement, however, is 
only justifiable so long as the observations correspond with those typical of 
the particular disease, and so long as they are in harmony with the other 
general signs of its course ; but as soon as notable deviations from these con- 
ditions are observed, the physician ought to make the observations for him- 
self. A difference of 2° Fahr. is not of any practical importance unless it is 
persistent. 

In prolonged and severe cases an examination of the records of temperature 
made during the course of the disease will recall to mind the nature of the 
case more effectively than the most detailed written history. For this pur- 
pose it is desirable to exhibit on paper the daily thermometric changes, in 
the form of an angular line or a curve, and to note in the proper places short 
memoranda of the more important incidents or therapeutic events which 
have taken place during the progress of the disease. Details illustrative of 
the changes in the pulse and the respiration, and amount of excreta, ought 
to be entered in the same sheet, as exhibited at pp. 248 and 249 following.* 

* Some thermometers are graduated to Centigrade as well as to Fahrenheit on the 
same glass stem ; and some have the Centigrade scale marked on the wooden tubes 
which inclose the thermomfter. The presence of two scales on one thermometer is 
too confusing for delicate ob.«ervation ; and it is better to have only one, converting 
that one scale into the other, if necessary, by calculation or by means of the tables 
commonly employed for this purpose ; the form for filling up giving (as at pp. 248, 
249) the double scale of Fahrenheit and Centigrade. 

Pahrenhbit Scale Comparbd with Centigrade and Ebaxjmitr's. * 



Fahr. 


Cent. 


Reau. 


Fahr. 


Cent. 


Beau. 


1120 


44.44 


35 55 


1010 


88.33 


30.66 


111.2 


44 


35.2 


100.4 


88.0 


80.4 


111.0 


43.88 


35.11 


100 


37.77 


30.22 


110.0 


43.33 


34.66 


99.0 


37.22 


29.77 


109.4 


43 


34.4 


97.6 


37 


29.6 


109 


42.77 


34.22 


97.0 


36.11 


28.88 


108.0 


42 22 


33.77 


96.8 


860 


28.8 


107.6 


42.0 


33.6 


96.0 


35.55 


28.44 


107.0 


41.60 


38.38 


95.0 


35 


28 


106.0 


41 11 


32.88 


94.0 


34.44 


27.55 


105.8 


41.0 


32.8 


98.2 


34 


27.2 


105.0 


40.55 


3244 


93.0 


38.88 


27.11 


104.0 


40.0 


32.0 


92.0 


33.88 


26.66 


103.0 


39.44 


81.55 


91.4 


83 


26.4 


102.2 


39.0 


81.2 


91.0 


32.77 


26 22 


102.0 


38.88 


31.11 


90.0 


32.22 


25.77 



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SCALES OF TEMPEBATUKE COMPARED. 



247 



In chronic eases, when febrile attacks and their^concomitant dangers may- 
be expected, as well as in acute cases, after return of the normal blood-heat, 
one daily observation will be found sufficient. This single observation may 
be best made in the afternoon, evening, or midnight. 

It is advisable to induce nurses, friends, or other attendants on the sick 
(whenever they seem apt pupils), who may make notes of any considerable 
excitement or restlessness, or take notice of hot hands, or increased heat of 
head, rather to consult at once the thermometer than trust to their sensations. 
They may thus, perhaps, tranquillize the patient and his friends when the 
instrument does not indicate any material increase of heat ; but the sudden 
appearance of any considerable increase of temperature would always be (as 
stated) a fact of vital importance. 

It has been recommended by some to place the thermometer under the 
tongue, as the best place. On the contrary, the cavity of the mouth is the 
worst place in which the thermometer can be put, in patients not accustomed 
to such obstructions, because ■ the temperature there is continually varying 
according to the quantity and temperature of the air used in respiration ; and 
if the atmosphere is cold; and deep inspirations are made, large differences 
may be observed, compared with the temperature in the axilla. Therefore 
observations made with the thermometer in the mouth are not generally trust- 
worthy, unless verified by observations in the axilla, groin, rectum, or bladder. 
Five minutes is found quite sufiicient for the application of the thermometer, 
if certain precautions are taken. The simplest and most convenient way is to 
heat the instrument before inserting it into the patient's axilla, just as the 
surgeon heats the catheter before he introduces it into the urethra. Neglect 
of this precaution is apt to lead to an uiider statement of temperature. It 
may be heated by holding the thermometer in the warm hand till the mer- 
cury shows a temperature of 98°; and after the instrument is properly placed, 
be satisfied if two ohaervations at intervals of one to two minutes give exactly the 
same result. 



Comparison- of the Scales fob bach Tenth of a Degkbe. 



Cent., , 
Fahr., . 
Reau., , 

Fahr., 
Cent., , 
Eeau., , 

Eeau , 
Fahr., 
Cent., , 



0.1 

0.18 

0.08 

0.1 

0.06 

0.04 

0.1 

0.22 

0.12 



0.2 


03 


0.36 


0.54 


0.16 


0.24 


0.2 


0.3 


Oil 


17 


0.09 


0.13 


02 


0.3 


45 


0.67 


0.25 


0.37 



0.4 

0.72 

0.32 

0.4 

0.22 

0.18 

0.4 
0.9 
0.5 



0.5 
0.9 
0.4 

0.5 

0.28 

0.22 

0.5 

1.12 

0.62 



0.6 

1.08 

0.48 

0.6 

0.33 

0.27 

06 

1.35 

0.75 



0.7 

1.26 

0.56 

0.7 

0.39 

0.31 

0.7 

157 

0.87 



0.8 

1.44 

0.64 

08 
0.44 
36 

0.8 

1.80 

1.00 



0.9 

1.62 

0.72 

0.9 
0.5 
0.4 

0.9 

2.02 

1.12 



1.0 
1.8 
0.8 

1.0 

0.56 

0.44 

1.0 

2.25 

1.25 



To convert degrees Centigrade atove zero to degrees Fahrenheit : multiply by 1.8, 
and add 32, or multiply by 9, divide by 5, and add 32. To convert degrees Centigrade 
below zero to degrees Fahrenheit : multiply by 1 8, and subtract from 32. To convert 
degrees of Centigrade into those of Reaumur : multiply by 4, and divide by 5. To 
convert degrees Reaumur above zero to degrees Fahrenheit ; multiply by 2.25, and 
add 32. To convert degrees Reaumur belo-w zero to degrees Fahrenheit : multiply by 
2.25, and subtract from 32. To convert degrees Reaumur into those of Centigrade : 
multiply by 5, and divide by 4. To convert degrees of Fahrenheit into those of Cen- 
tigrade: deduct 32, multiply by 5, and divide by 9. To convert degrees of Fahren- 
heit into those of Reaumur : deduct 32, divide by 9, and.multiply by 4. In De Lisle's 
thermometer, used in Russia, the graduation begins at boiling-point, which is marked 
zero, and the freezing-point is 150. 



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248 



TOPICS RELATIVE TO PATHOLOGY. 



RECORDS OF TEMPERATURE, PULSE, 



In the case of. 

JE!tat. ...., Occupation. 



.Ward . 



DATES OF«C? 
OBSERVATIONS 






























°*YS OF ^^ 
DISEASE ""^ 






























TEMPEPATtRE 
CENTIGRADE 


TEMPERJTUR 
FAHRENHEIT 


E TIME 


TMI£ 
ANl;P^ 


TIME 

rn-pn 


r/nE 

m- PN 


TIME 
AM' PM 


71HE 
AM- PB 


TIME 
AH- PN 


TIME 
AM-PK 


TIME 

m . PAi 


TIME 
AM-PN 


TIME 
AM^PN 


TIME Tim Tim 
AM^PN AM.-PHAH.PII 


4I» 


106° 


3 


























































40' ' 


- 1050 


- 104° 






























3S'~ 


- 103° . 




' .' 


























"■ 






























38' ' 




- 101° i 






























- j 


■ 
■ 
















; 














- 100° z 


8 
- 99° 2 


■ 




























37 • 


- 1 


• 






























TEMPERJITURE 


- 38" S 












• 




















= 97° i 




























; 




8 

f 

- 96° : 






: 




! 


; 


















PULSE PEB MINUTE 






























RESPIRATIONS 

PER MINUTE 






























"«l«^ tc'^ns 






























REACTION OF 






























- SPECF.GR.OF 






























COLOUR OF 






























CLEARorTURBID 






























UREA (amount) 






























SUGAR IN 






























ALBUMEN IH 






























SOLIDS IN 






























MICROSCOPIC 
SEIDIMENTS 








• 
















- 




' 


STOOLS NUMBER 
I. CHARACTER 






• 

























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RECORDS or TEMPERATURE, ETC. 



249 



EESPIEATION, AND EXCRETA (See p. 246). 

Disease Termination.. 

Begister Folio 











1 




























































TIME 
AM-PW 


rai/r 

AM-PM 


r/4f£ 
AM'PW 


TIME 
4IH- PH 


TIME 
AM. PN 


TME 
AM■P^ 


TIME 

AM- P» 


TIME 
AM- PM 


AM • PN 


AM- PN 


TIMC: 

AM-PM 


AM- PiV 


TIME 

m ■ p^ 


AM-PN 


7-/ȣ- TIME 
AM- PN AM-PM 


TIME 
AH- P» 






























































































































- ; 










t 
































• 






































1 








































































































































1 : 


















































• 
















































































































































































































































































































































































































































J 































































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250 TOPICS RELATIVE TO PATHOLOGY. 

The rapidity witt wliicli the mercurial column rises depends on the degree 
of temperature present. The rapidity of the rise of temperature ought to he 
noted, as well as the maximum height. If the temperature be above the nor- 
mal standard, a sensitive thermometer will indicate that fact within the first 
minute; and as the quickness of the rising depends upon the existing tem- 
perature, the physician is able, after some experience in the use of a particular 
instrument, to form an approximative judgment of the amount of rising of tem- 
perature to be expected in any particular case from the slowness or rapidity 
of the rise of the mercury after half a minute. 

II. Fluctuations of Temperature within the Limits of Health ; and the Corre- 
lation of the Animal Heat with the Pulse and the Respiration. 

Several observers in Germany, France, England, and the Tropics, have 
now determined these fluctuations with great accuracy, so that ample and 
sufl[icient data are on record to furnish a standard for comparison in cases of 
disease. 

The temperature of the body is the result of the opposing action of two 
factors : 1st, Development of heat from the chemical changes of the food, and 
by the conversion of mechanical force into heat, or by direct absorption from 
without; and 2d, and opposed to this, Evaporation from the surface of the 
body, which regulates internal heat (Parkes's Hygiene, p. 432). 

With reference to the normal range of temperature, our most trustworthy 
information is mainly due to Valentin and Traube, in Germany ; to Edwards, 
Becquerel, Breschet, and Bernard, in France; to Dr. William Ogle, in Eng- 
land ; and to Dr. Alexander Rattray, Surgeon ia the Eoyal Navy, in tropical 
and temperate climates. It is generally agreed that the ranges of tempera- 
ture vary in different parts of the human body ; but, as a general practical 
result, it is equally agreed that in temperate regions the normal temperature, 
at completely sheltered parts of the surface of the human body, amounts to 98.4° 
Fahr., or a few tenths more or less at different times of the day ; and a rising 
above 99.5°, or a depression below 97.3° Fahr., are sure signs of some hind of 
disease, if the increase or depression is persistent. 

Valentin proved by many experiments that all warm-blooded animals sur- 
rounded by an atmosphere of 50° Fahr. to 68° Fahr. have a temperature of 
about 99.5° in the back of the mouth, the rectum, or other accessible internal 
parts; and at completely sheltered parts of the surface it is about 97.5° to 98.4° 
or .5°. According to Ringer and Stewart, in persons under twenty-five, the 
average maximum temperature is 99.1°; over forty years of age, it is 98.8°. 
In the second childhood of old age it again rises (Albutt). Dogs have a 
temperature similar to that of men. A knowledge of thermometry, there- 
fore, in the diseases of animals, will prove not less valuable in veterinary 
pathology than in human, and perhaps more so, inasmuch as animals de- 
prived of speech are unable to express their feeling. In the cattle plague of 
1866-67, the use of the thermometer was found of great practical value in 
diagnosis. 

The observations of Dr. John Davy, originally communicated to the Royal 
Society, have been shown by Dr. William Ogle to be so full of errors, that 
they are really without value. The following records are believed to be the 
most trustworthy : 

The minimum temperature is from 1.30 A.m. to 7.30 a.m. (Jdegensen). 
The lowest temperature occurs about daybreak, about 6 a.m. At this time a 
rise begins, which continues till late in the afternoon, and it commences while 
yet the body is in complete repose, and when no food has been taken for ten 
or twelve hours ;. but coincidently with this rise there is an increase in the 
exhalation of carbonic acid (Ogle) and of urea ; so that the rise is doubtless 
due to increased chemical change or resumed activity of organic functions, as 
the intensity of sleep diminishes towards morning. 

The highest range of daily temperature is maintained between 9 a.m. and 



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NORMAL TBMPBRATUKE OF THE HUMAN BODY. 



251 



6 P.M. After this time the temperature falls slowly and continuously, if no 
alcohol be taken ; but if alcohol be taken with the evening meal, the fall is 
more sudden (Ogle). Otherwise food seems to have little influence on nor- 
mal temperature, except, perhaps, with infants. Although the records may 
vary somewhat, yet one elementary fact stands clearly out — namely, that in 
a healthy man the limits of fluctuation, imder various conditions, are very 
narrow, and independent of external temperature. This constancy of the 
bodily temperature is a consequence of the remarkable regulation of evolu- 
tion and loss of its heat, and is the expression of their difference. The 
average variation in the course of twenty-fours is about 1.5° Fahr. A 
general average for the day may be stated as follows : 



Before 
Breakfast. 


11 A.M. 
2 p.m. 


3 P.M. 
5 P.M. 


6.80 P.M. 
7.30 P.M. 


9 p.m. 
10 P.M. 


12 P.M. 
12.30 A.M. 


12.30 A.M. 
1 A.M. 


3 A.M. 
5 A.M. 


5.30 A.M. 
6.30 A.M. 


8 A.M. 

9 a.m. 


97.73° 


98,2° 


98 36° 


98.63° 


98° 


97.96° 


97.9° 


97. -5° 


97 2° 


97.6° 



Dr. Rattray's observations were made by placing an ordinary Fahrenheit, 
thermometer under the tongue thrice a day during a voyage from England 
to Bahia (lat. 11° S.) and back — i. e., across the Equator — extending over 
sixty days (fifty-three in the tropics, and seven in the latitude of England, 
51° N.). During this period the temperature of the air in the shade on the 
verge of the tropics was 72° Fahr.; at the equator, 84° Fahr.; and the 
average of the tropics generally, 76.9° Fahr. The atmospheric humidity 
ranged from 0° to 7.5° ; the average being 3.8° of a Mason's hygrometer. 

In England, with a temperature ranging from 60° to 70° Fahr., the average 
temperature of the body was 98.3° Fahr. ; it rose in the tropics to 98.6°, and 
in the equatorial doldrums to 99° Fahr., and occasionally even to 100° Fahr. 
In the tropics the temperature of the body is greatest during the afternoon, 
when the sun is high, and the body most active, and least in the morning. 
The pulse is likewise highest and lowest at these times. The totals show 99° 
Fahr. to be the most frequent bodily temperature, while 99.5° and 100° Fahr. 
form 22 per cent, of all the observations, and the range of temperature about 
2° Fahr. daily (Proceedings of Royal Society, No. 122, p. 613, June 16, 1870). 

The following are the collateral circumstances which mainly influence 
animal heat in our daily life, and which require to be remembered, in order 
that erroneous conclusions may not be drawn: (1.) Active exercise (not carried 
to the extent of exhausting fatigue) raises the temperature proportionally to 
the degree of muscular exertion made. (2.) Exposure to cold without exercise 
lowers the temperature. (3.) Sustained mental exertion reduces the tempera- 
ture about half a degree. Lombard states the reverse to be the fact. (4.) 
The amount of heat is also at first reduced after a full meal and after alcohol; 
but it rises again as digestion advances. According to Df. William Ogle, it 
causes a rise most marked after breakfast, less so after lunch, and which is 
reduced after dinner to a mere retardation of the fall, which without it would 
occur. (5.) Alcohol (claret) causes an immediate rapid fall, which is tempo- 
rary, and a reaction occurs by which the temperature is carried to as high a 
point, or even higher, than it would have reached if no alcohol had been 
taken. Tea causes an elevation of temperature. (6.) Sex, race, latitude, 
seasons, weather, habits of life, and idiosyncrasies go for very little in influ- 
encing the temperature of healthy persons. (7.) On the other hand,_the tem- 
perature in disease is more readily and rapidly afiected — more sensitive, so to 
speak — than either the pulse or the respiration, and the increase or variations 
are persistent as long as disease exists. 

The amount of abnormal increase of temperature is usually proportionate 
to the degree of frequency of the pulse, and to the other signs of general 

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252 



TOPICS RELATIVE TO PATHOLOGY. 



disease. Yet such congruity of phenomena is sometimes in part or wholly- 
absent or incomplete ; and in the cases in which a disproportion or incongruity 
exists between the increase of temperature and the pulse, or other febrile phe- 
nomena, it is the accurate measurement of the temperature which is most of 
all to be relied upon. 

As a general rule, the correlation of pulse and temperature may be stated 
as follows, namely : An increase of temperature of one degree above^ 98° 
Fahr. corresponds with an increase of about eight beats of the pulse per minute, 
as in the following table : 



A temperature of 98° 
" 99° 

" 100° 

" • 101° 
" 102° 

" 103° 

104° 
" 105° 

" 106° 



Corresponding with a pulse of 72 (Health) 
Ought to correspond with a pulse of 80 

u u u 88 

" " " 96 

a 11 11 108 

11 II 11 112 

'1 11 " 120 

" " " 128 

11 11 11 136 



This statement is, however, in some respects arbitrary, and is given for the 
convenience of comparing different diseases with some standard. In some 
diseases a high temperature is found with a low pulse, and a low temperature 
with a high or rising pulse. The pulse, too, sometimes rises in rapidity when 
the temperature falls, or falls when the temperature rises. 

Dr. John Beddoe, Physician to the Bristol Royal Infirmary, records a pecu- 
liar case of enteric fever, in which the most notable point was the coexistence 
of an elevated temperature with an abnormally slow pulse, and but a mode- 
rate rate of wasting. . _ 

In children the records are contradictory. For example: According to 
the observations of M. Roger and Dr. Holland, the temperature of children 
is somewhat higher than adults, when placed in conditions favorable to suste- 
nance. At birth the temperature of the infant is the same as that of the 
mother, but quickly falls to 93.4°, or 95.5°, rising in the course of twenty- 
four hours to 97.7°, — i. e., more than half a degree below adult heat (Mac- 
lagan). Between four and six years of age, M. Roger found the tempera- 
ture to be 98.9^ Fahr.; and between six and fourteen years, 99.16° (Caepen- 
tee). Dr. Bennett states generally, that in children the heat of the body is 
about 2° higher than in adults. 

On the other hand, among numerous written statements sent me on this 
subject, from actual observation, I find results are varied, — many opposed to 
the preceding statements. For example, during an epidemic of measles in 
Glasgow, in 1866, Mr. James P. Cassels, while using the clinical thermometer, 
was much struck with the low temperature recorded in some eases after com- 
plete recovery. The following shows the result of six observations on a baby, 
16^ months old, and in perfect health since birth, taken wh&n asleep, and every 
source of error carefully avoided. His observations show results below those 
of adult life : 



Date of 
Observation. 


Hour. 


Tempera- 
ture of 
Boom. 


Temperature of Body. 


Respi- 
rations 

per 
Minute. 


Pulse 
per 
Min- 
ute. 

106 
106 
100 
112 
100 
120 


Time during 
which Thermo- 
meter If as in 
close contact 
■with Skin. 


Phillip's 
Thermo- 
meter. 


Curved. 
Thermo- 
meter. 


July 3, 1866. 
July 5, 1866. 
JulV 6, 1866. 
July 11,1866. 
July 28, 1866. 
July 30, 1866. 


10.20 P.M. 
10 20 P.M. 
10 30 P.M. 
10.30 P.M. 
10.20 P.M 
12 midnight. 


65° Fahr. 
65° Fahr. 
64° Fahr. 
69° Fahr. 
68° Fahr. 
68° Fahr. 


96^° 
96f° 

96r 

97^° 
97f° 
97§° 


96i° 
96 1° 
96|° 
964° 
97i° 
97f° 


23 
22 
22 
22 
25 
22 


25 minutes. 
30 minutes. 
25 minutes. 
40 minutes. 
25 minutes. 
20 minutes. 



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USEFULNESS OF THE CLINICAL THBRMOMBTEK. 253 

III. Ranges of Temperature in Disease. 

Having satisfied ourselves as to the delicacy and accuracy of the thermom- 
eter, and obtained a standard for comparison, we are prepared to appreciate 
the ranges of temperature in febrile diseases as measured by such an accurate 
instrument. 

The maintenance of a normal temperature, within the limited fluctua- 
tions just noticed, under all these varying influences, gives a complete assur- 
ance of the absence of anything beyond local and unimportant disturbances ; 
and, long before the subject was worked out so thoroughly as it has been, it 
was often casually observed that any acute disease, however slight, elevates 
abnormally the temperature or animal heat ; " and its undue degree of eleva- 
tion (as Dr. Davy clearly enunciated) is some criterion of the intensity of the 
diseased action" {Phys. Researches, vol. i, p. 56). In short, it is now placed 
beyond a doubt by the observations of Gierse, Roger, Valentin, Von Bseren- 
spriing, Wunderlich, Friedlander, Virchow, Traube, Jockmann, Greisinger, 
Billroth, and others, in Germany ; by MM. Becquerel, Breschet, and Bernard, 
in France ; by Parkes, Jenner, and Ringer, in this country, that while this 
preternatural heat varies in amount in different diseases, in different persons, 
and at different times of the same day, it is this preternatural heat which is 
the essential symptom in fever, which proves fever to be present, and which 
exists to the extent of 4°, 6°, or even 8° Fahr. over the natural limits of 
health, and must be estimated by the temperature in the axilla or rectum, as 
indicated by the thermometer. This preternatural heat is never absent in 
fever, and without it fever cannot be said to exist. Rigor, which is also some- 
times present, is a mere peripheric phenomenon. The coldness of the skin, 
so much complained of by the patient, is usually a subjective sensation, pro- 
duced by the state of the peripheral nerves, and is not due to any actual 
decline of temperature; for even "while the outer parts feel cold to the by- 
stander, the inner parts are abnormally warm. While the outer parts freeze, 
the inner burn " (Viechow, Pakkes, Jenner). 

There are many cases now on record in which the physician, without ther- 
mometric observation, does not appreciate the existence of fever or of danger. 
Wunderlich gives numerous examples of this ; but long before he brought 
this subject so forcibly to the notice of medical men, we have the testimony 
of Dr. John Davy in this country, given quite incidentally, and therefore all 
the more valuable as an unbiassed testimony of the usefulness of the ther- 
mometer in detecting latent disease not otherwise indicated by general symp- 
toms. When Dr. -Davy was collecting his extensive observations on the 
normal temperature of the body, he was surprised to find that one person 
exhibited for many weeks a persistent temperature of 104° Fahr. This person 
was a lunatic soldier ; and Dr. Davy remembered that the insane do not seem 
to suffer from cold nor heat like ordinary individuals, and that there are 
certain organic lesions which are apt to occur in them unaccompanied by the 
usual symptoms. For example, tubercle and cavities of the lungs occur with- 
out cough or difficult breathing ; and although no warning nor any indication 
may be given, the disease runs its course, terminating in death as certainly and 
as rapidly as if indicated by the ordinary train of symptoms. Discovering, then, 
as it were by accident, that the temperature in this lunatic was as high as 104.5° 
Fahr., and that his pulse was rapid, Dr. Davy's attention was more particu- 
larly aroused ; and although the man made no complaint, but had a good 
appetite, with his digestive functions, so far as was known, acting well, yet 
disease of the lungs was thus discovered ; and was confirmed by the examina- 
tion of his chest yielding the usual physical signs of disease. The lunatic died 
in a month, of acute tuberculosis, "not otherwise expressed by symptoms 
beyond the great, persistent, and continuous elevation of temperature thus 
incidentally noticed. There were ulcers of the larynx found after death, but 
there tad been no affection of the voice ; there were vomicw and tubercles in 

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254 TOPICS RELATIVE TO PATHOLOGY. 

the lungs, but there had been no cough ; there were ulaerations of the intestines, 
but there had been no diarrhoea ; there was disease of the testes, vesieuke 
seminales, and prostate, of a severe kind, but these lesions had been equally 
latent during life, except hardening and enlargement of the testicle without 
pain, — all which conditions were only casually observed. 

In this very instructive case a temperature of six degrees Fahr. above the 
normal standard was the earliest indication of disease {Researches, Physiologi- 
cal and Anatomical, vol. i, p. 206). 

But it is mainly to Wunderlich, the Professor of Medicine in Leipsic, that 
we are indebted for an elaborate exposition and persevering advocacy of the 
usefulness of daily records of the temperature of fever patients, and the con- 
stant employment of the thermometer as a means of diagnosis at the bedside. 
On this subject he has written much, from an extensive experience, embra- 
cing at least half a million exact thermometric observations, following the 
continuous progress of individual diseases, the results of which he has com- 
pared in more than 5000 patients. He constantly employs the thermometer 
in his private practice, and bears unqualified testimony to its sterling value 
in the early detection of disease, and as often furnishing an important guide 
to treatment. When the physician once becomes accustomed to the investi- 
gation of disease by the thermometer, he regards its daily employment as in- 
' dispensable, for it imparts a certainty to his observations, attainable by no 
natural penetration, and which no other method of investigation can convey 
(Medical Times and Gazette, June 19, 1858, and September 28, 1861). 

Wunderlich gives some striking instances of disease being indicated by 
thermometric observation before it could be detected by any other means : 

In ague, several hours previous to the paroxysm, the temperature of the 
trunk of the patient's body begins to rise ; and when the disease seems to have 
disappeared, an increase of temperature may be detected periodically, unac- 
companied by any other symptom. So long as this periodic rise of tempera- 
ture continues, the patient is only apparently, but not really cured. 

In enteric fever, during the exacerbations especially, the rise of temperature 
or its abnormal fall may indicate what is about to happen three or even four 
days before any change in the pulse, or other sign of mischief, has been 
observed. A sudden and marked reduction of temperature has thus denoted 
hemorrhage from the sloughs of Peyer's patches in typhoid fever several days 
before it appeared in the stools. A case of this kind is recorded by Dr. 
Parkes. It occurred in a female twenty-five years of age. Diarrhoea was 
considerable, and blood was largely passed in fluid stools the night before the 
seventeenth day of the fever. On the morning of that day the temperature 
was as low as 93° Fahr., rising in the evening to 101° Fahr. 
_ It is rare, however, that a definite diagnosis or prognosis can be based on a 
single observation ; but sometimes certain conclusions may be arrived at, as 
in the following instances : 

When the temperature is increased beyond 98.5° or 99° it merely shows 
that the individual is ill, and suffering from some disease ; and that when 
considerably raised, as with a temperature of 101° to 105° Fahr., the febrile 
phenomena are severe ; that when a great height is reached, as at temperatures 
above 105° Fahr., the patient is in imminent danger ; and that with a rising 
. temperature above 106° Fahr., to 108° or 109° Fahr., a fatal issue mayalmost 
without doubt be expected in a comparatively short time. The highest tem- 
peratures before death have been observed in cases of scarlet fever and of 
tetanus. 

A definitive diagnosis may also be based on a single observation, under the 
following circumstances : 

A person who yesterday was healthy, but exhibits this morning a tempera- 
ture above 104° Fahr., is almost certainly the subject of an attack of ephem- 
eral fever or of ague; and should the temperature rise up to or beyond 



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USEFULNESS OF THE CLINICAL THERMOMETER. 255 

106.3° Fahr., the case will certainly turn out one of ague, or some other form 
of malarious fever. 

A girl eighteen years of age, supposed to be suffering from hysteria, but 
. simulating a case of cerebro-spinal meningitis. A. temperature of 103.5° con- 
firmed the diagnosis of meningitis and negatived that of hysteria. The case 
terminated fatally (Compton). Again, in a patient whose temperature rises 
during the first day of illness up to 106° Fahr., it is certain he does not suffer 
from typhus nor enteric fever ; and of a patient who exhibits the general 
typical signs of pneumonia, but whose temperature never reaches 101.7° Fahr., 
it may be safely concluded that no soft infiltrating exudation is present in 
the lung. 

Again, if a patient suffer from measles, and retains a high temperature 
after the eruption has faded, it may be concluded that some complicating 
disturbance is present. 

Single observations of temperature, combined with a careful consideration 
of all the symptoms, will often determine whether the disease is one of danger 
or not. 

. In enteric fever a temperature which does not exceed on any evening 103.5° 
Fahr. indicates a probably mild course of the fever — and especially if the 
increase of temperature takes place moderately, towards the beginning of the 
second week. A temperature of 105° Fahr. in the evening, or of 104 Fahr. 
in the morning, shows that the attack is a severe one, and forebodes danger 
during the third week ; on the other hand, a temperature of 101.7° Fahr. and 
below, in the morning, indicates a very mild attack, or the commencement of 
convalescence. In pneumonia a temperature of 104° Fahr. and upwards 
indicates a severe attack. In acute rheumatism a temperature of 104° Fahr. 
is always an alarming symptom, foreboding danger, or some complication, 
such as synovial or pericardial inflammation. In a case of jaundice otherwise 
mild, an increase of temperature indicates a pernicious turn. In a puerperal 
female an 'increase of temperature indicates approaching pelvic inflammation. 
In tuberculosis an increase of temperature shows that the disease is advancing, 
or that untoward complications are setting in. 

In short, a fever temperature of 104° to 105° Fahr. in any disease indi- 
cates that its progress is not checked, that complications may still occur, and 
that the case is a precarious one. 

But it is by continuous daily observations that the most important results 
have been arrived at, especially in the hands of Wunderlich, Greisinger, 
Traube, Billroth, Parkes, Jones of Augusta, Einger, and others who are now 
working most actively in this fleld of labor. 

Certain febrile diseases have been found to have typical ranges or daily 
fluctuations of temperature throughout their course. In pure unmixed and 
uncomplicated cases, this is found to be so constant that the differential diagno- 
sis may be established by accurate observation of the temperature continuously 
from day to day. This has now been determined, especially in cases of mala- 
rious fever, typhus, enteric fever, small-pox, scarlatina, measles, rheumatism, 
pyaemia, pneumonia, acute tuberculosis. In each of these diseases the tem- 
perature is one of the most certain (although not the only) means for deter- 
mining the real state of the patient as regards morbid, disturbances or complica- 
tions ; and a careful observation of temperature from day to day, considered 
in relation with other signs, is indispensable for judging as to the prognosis. 
Frequently it affords the only ultimate means of deciding in doubtful cases, 
and often it is the best corrective of a too hasty conclusion : for example, the 
characteristic variations of the temperature, in a typical case of enteric fever, 
are of such a kind that they are not found in any other disease. Intestinal 
catarrh, severe forms of pneumonia, malarious fever, acute tuberculosis, men- 
ingitis, some stages of Bright's disease, may each simulate enteric fever, and 
may exhibit some of its most characteristic symptoms ; but observation with 

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256 TOPICS EELATIVB TO PATHOLOGY. 

the thermometer as to the patient's temperature from day to day, will at once, 
or after a very, few days at most, establish the distinction with certainty. 

In the course of many diseases, whose diagnosis has been accurately deter- 
mined, if the temperature departs from its normal or typical range, the ther- 
mometer will furnish the best and the earliest indication of any untoward 
event, such as the additional development of disease, or of visceral complica- 
tions in its course. 

When once the typical range of temperature (normal to the particular 
disease) is determined, an important point in its natural history has been fixed, 
and a basis is laid for appreciating irregularities or complications in its course 
in particular cases. For example, a patient exhibits symptoms of fever of 
the typhoid type, but during the progress of the first week his temperature 
becomes normal, for however short a space of time ; — the occurrence of this 
event proves that the fever is not what it was supposed to be. Again, a patient 
may suffer from all the general symptoms of incipient pneumonia ; but there 
still is a doubt as to whether infarction of the lung has taken place. The 
sputa being suppressed, or not procurable, does not assist the diagnosis. If, i 
•however, the temperature is found to be normal, it is certain that no croupous 
exudation has taken place in the lung, and that there is no pneumonia. 
Again, if a tuberculous patient has a sudden attack of hsemoptysis, and if the 
temperature of his body is normal during and subsequent to the attack, no 
reactive pneumonia, nor any exacerbation of the tuberculous exudation, need 
be expected. This is a new field open for investigation in cases of phthisis. 

Again : In all cases of convalescence, so long as the defervescence proceeds 
regularly as measured by the temperature, no relapses need be feared : on the 
other hand, delayed defervescence in pneumonia, the persistence of a high 
evening temperature in general diseases, and the incomplete attainment of 
normal temperature in convalescence, are signs of great significance. They 
indicate incomplete recovery, supervention of other diseases, or local lesions, 
unfavorable changes in the products of disease, or the continuance of other 
sources of disturbance requiring to be carefully examined into. The onset of 
even a slight elevation of temperature during convalescence is a warning to 
exercise careful watching over the patient, and especially for the maintenance 
of a due control over his diet and actions. 

Continuous daily observations by the thermometer show the typical ranges 
of temperature in particular forms of fever, and supply the grounds or basis 
by which it is determined whether any individual case is progressing as it 
ought to do. Such knowledge can only be acquired by repeated observation 
of numerous cases ; and deviations from the normal temperatui-e in certain 
diseases are stable in proportion to the typical character and full development 
of the particular disease. But even in such diseases we may have an increase 
or decrease of temperature proper to the disease brought about by aocidental 
influences. Such instability, however, is only temporary, and of short dura- 
tion, when the aocidental influences act but transitorily. For example, the 
temperature proper to the disease may be lowered under the influence of a 
profound sleep, bleeding, epistaxis, the relief of constipation or of the reten- 
tion of urine, and the like ; or it may be raised after excitement of a mental 
kind. But any such alterations, unless they are dependent upon a change in 
the disease-process itself, will become effaced after twelve or twenty-four hours 
at the most, when the temperature again resumes the typical character diag- 
nostic of the particular disease. In continued fevers the temperature is gen- 
erally less high in the morning than in the evening. 

Stability of temperature from morning to evening is a good sign ; on the 
other hand, if the temperature remains stable from evening till the morning, 
it is a sign that the patient is getting or will get worse. 

When the temperature begins to fall from the evening to the morning, it is 



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USEFULNESS OF THE CLINICAL THERMOMETER, 257 

a sure sign of improvement ; on the other hand, a rise of temperature from the 
evening tilHhe morning is a sign of his getting worse. 

When it is found, in a bad case of enteric fever, that some morning about 
the third week the temperature has fallen to 99.5°, the reparative stage has 
begun— the healing of Peyer's patches ; and when a similar fall of tempera- 
ture is observed in the evening, convalescence has commenced. 

In pnnmionia, when a marked fall of temperature occurs in the evening, 
the period of crisis has arrived. 

In measles, when the maximum severity of the eruptive stage has been 
reached, the temperature falls. 

A sinking from a considerable height down to a normal temperature sud- 
denly (within twenty-four hours), occurs in a few eruptive fevera,~measles, 
variola, rarely in pneumonia, tyj)Iius, and pyasmia. 

In scrofula, especially in its acute form, with deposition or growth of tuber- 
cle, the persistent maintenance of a uniformly high temperature will alone 
show that no arrest in the progress of the disease has occurred. 

The correlationof pulse, respiration, and temperature is of great importance 
to be determined in many acute diseases ; and especially in pneumonia, if the 
mean of the temperature is not above 104° Fahr., and that of the pulse is not 
above 120 iu a minute, and the mean of the respirations not over 40 in the 
same time, the case must be considered a slight one ; and if the patient is 
otherwise healthy, he will surely begin to get well in from eight to twelve 
days, without any medical treatment beyond attention to antiphlogistic 
regimen. 

In typhus fever, a falling temperature with a rising pulse forebodes danger. 

Convalescence is known to commence when the disease-process ends ; and 
riiis precise point can only be fixed by continuous thermomctric observation. 
The morbid process does not end till the normal temperature of the body 
returns, and maintains itself unchanged through all periods of the day and 
nidit. 

Regularly continuous observations of the temperature exhibit the precise 
point at which the disease-process terminates, and the degree of its complete 
development. When this point has been determined on, a retrospective view 
may be taken of the character of the disease, as to the purity of its typical 
form or its complexity, and a prognosis may be hazarded as to the probability 
or doubtfulness of recovery. The morbid process has not terminated till the 
normal temperature of the body returns, and remains unchanged in the eve- 
nmgs and throughout all periods of the day. The transition from the febrile 
state into _ defervescence being either slow (lysis) or rapid (crisis) ; and regu- 
larly continuous defervescence is always a sure sign of convalescence. Irreg- 
ular defervescence, on the contrary, indicates a disturbed and protracted 
course of convalescence, which requires careful watching and judicious 
nursing. 

It is of practical importance to know that the fall of temperature during 
the period of recovery, in eases of considerable morning remissions, as well as 
m those of continued defervescence, may be abnormally large, arid sink as 
low as 28° R. = 95° Fahr., or even lower. Such events constitute collapses 
during defervescence, which must be counteracted by artificial heat, the 
administration of warm drinks, or even of such stimulants as wine or camphor, 
unless some unexpected new danger should interfere with an otherwise favor- 
able course of the disease. 

During pouvalescence the recurrence of a high temperature is generally 
the first sign of an approaching relapse, or the onset of a new disease, the 
characteristic symptoms of which it may precede by several days. The per- 
sistence of even an inconsiderable degree of abnormal temperature after 
apparent return to health, is a certain, and frequently for a long time the 
only, sign of incomplete recovery, or the existence of some lingering secondary 

VOL. I. 17 

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258 TOPICS RELATIVE TO PATUOLOGT. 

disease. The temperature should therefore be closely watched during conva- 
lescence; and the thermometer should be applied every alternate_ evening at 
the very least. As long as the temperature remains normal, nothing need be 
feared; but every rise of temperature should act as a warning. It may be 
due to mere error in diet, or to leaving bed too early; but in such cases the 
temperature soon sinks again, on greater precautions being taken. 

Kegularly continuous observations on the temperature alone, or in coiinec- 
tion with other symptoms, may enable the physician to predict a fatal issue 
with certainty, or the probably near approach of death. On this point one of 
two conditions may be observed. (1.) The temperature may rise continuously 
and considerably above 106.2° Fahr., when it is a bad sign; or it may even 
reach 110° Fahr., when a fatal issue is almost certain ; and it not unfrequently 
happens that, after the apparent occurrence of death, the temperature still 
continues to rise one or two-tenths Fahr., or even a degree, the cooling of the 
body taking place very slowly. Wunderlich records a case of spontaneous or 
rheumatic tetanus in which the temperature exceeded the maximum that has 
ever yet been observed in any disease. The heat only began to increase 
within the last twenty-four hours before death ; but the other symptoms before 
that time had been very violent, the respirations being accelerated, and the 
pulse at 102. During the night previous to death the temperature suddenly 
rose 3.3° Fahr., while the velocity of the pulse and the frequency of the respi- 
rations diminished, and the other symptoms did not increase in severity. 
Shortly before death, the heat rose to 110.75° Fahr., the pulse being then at 
180; and at the moment of death the thermometer, was at 112.5° Fahr. 
After death the temperature still rose, and was found to be 113.8° Fahr. an 
hour after the fatal event. It then slowly diminished ; and thirteen and a half 
hours after death the temperature had not yet fallen to the normal average of 
the living body. 

(2.) The temperature may become more or less moderated, while the pulse 
is increased in frequency, and the other symptoms become more and more 
threatening. Such diminution of temperature, amidst conditions which do 
not harmonize with it, must be regarded as a pretty certain sign of approach- 
ing dissolution (see cases published by Dr. Muller of Dundee in Brit, and For. 
Med. and Chir. Review, Oct., 1868). 

But, on the other hand, there are cases in which the observation of the 
temperature yields the most favorable signs for prognosis. For example, 
when it is found, in a bad case of enteric fever, that the temperature has fallen 
some morning to 99.5° Fahr., we know that the reparative stage is entered 
upon ; and when a similar fall of temperature is observed in the evening, con- 
valescence has commenced. In pneummiia, when a marked fall of tempera- 
ture occurs in the evening, it shows that the period of crisis has arrived. 
When the temperature falls in measles, the maximum severity of the eruptive 
stage has been reached ; and when, in the first stage of variola, we observe a 
quick return to the normal temperature, we may feel certain that a slight 
form of the disease, free from danger, is likely to ensue. 

A decrease of temperature helow the normal is rare. It happens sometimes 
transitorily, anouncing thereby a favorable crisis, by preceding the return to 
a normal temperature. It is also met with som'etimes during the morning 
remission oi remittent fever ; also during the apyrexia of intermittents ; in acute 
collapse, preceded or not by fever ; in chronic wasting diseases ; and sometimes, 
also, on the approach of death, especially in typhus fever, in which the car- 
diac symptoms have been dangerous. 

A remarkable inequality in the distribution of the temperature over dif- 
ferent parts of the body (face, hands, feet, &c.) may occur during the shiver- 
ing preceding fever, in collapse, and in the agony of approaching dissolution. 
Sometimes, also, such unequal distribution may occur in disorders of the chest 
and abdomen, in some local skin diseases, and in partial paralysis. This fact 



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CORRELATION OP BODILY HEAT WITH EXCRETA. 259 

is not of importance or utility for diagnosis or prognosis; but it requires to be 
known, in order that erroneous conclusions may not be drawn. 
. r, 9^ *^^ -Karejres 0/ Temperature in 'Diseases where Fever is present as related 
to the Amount of the Excreta. 

The particular degree of heat and the waste in every febrile disease are 
represented hy— something. The physician sees the fevered patient wasting 
before his eyes. Every tissue is wasting, and, in correlation with the exces- 
sive generation of heat, how is this waste expressed ? As a rule, it is expressed 
by the amount of excreta. 

_ To Dr. Parkes in this country, to Dr. Jones of Augusta (in cases of mala- 
rious fever), to Virchow and Wunderlich in Germany, is the merit mainly 
due ot having demonstrated, by clinical and experimental observation, that 
the morbid development of heat, as measured by a thermometer, is associated in 
some cases with more abundant, in other instances with less abundant excreta 
trom the body than in health;— that the temperature and the amount of the 
excretions bear some undetermined relation to each other;— and that the loss 
ot weight of the patient is due to increased and rapid elimination of material 
with increased tissue-change, associated with the increase of temperature. 
• ^ i!" ^1 P'lysiological facts have elucidated the normal generation of heat 
in the healthy body, so far has the abnormal generation of heat essential to 
the febrile state been clearly made out. In health the normal temperature 
produced by chemical change in the body is represented in the excretions by 
so much urea, sulphuric add, carbonic acid, excretive volatile acids of the skin 
and the like; but m the febrile body a higher temperature is represented in 
the excretions, m some cases by a larger, and in others by a smaller quantity 
oturea, sulpliune acid, and probably carbonic acid (Paekes). 

In the study of special diseases the student ought frequently to estimate the 
quantity of excreta passed by the urine, as one of the best methods for ena- 
blmg him to appreciate the changes which go on in the body during disease, 
fd him m prosecuting such researches, he is recommended to consult the 
work of Dr. Parkes On the Composition of the Urine, and to follow the direc- 
tions given on the Exami7iation of the Urine, towards the end of the second 
volume of this text-book, for obtaining quantitative results by the volumetric 
method. Here the following general results may be given : 

Average quantity of Urine passed in twenty-four hours, 
" amount of Solids, " " u 



Urea, 

" Chlorine, " 

" Free Acid, " 

" Phosphoric Acid, 

" Sulphuric Acid, 

" Uric Acid, 

Speciiic gravity, 



52| to 56 ounces. 

954 grains. 

512 " 

126 76 " 

33 " 

48.80 " 

81.11 " 

8.5 " 

1.020 



Two grams of urea per pound weight of the body is the minimum given by 
Haughton and others, eliminated as the product of vital work alone The 
urmary solids maybe estimated by multiplying the number of ounces of urine 
passed m the twenty-four hours into the number representing the speciiic 
gravity— the product being the weight of the solids in grains. A convenient 
table (see pp. 260 261) is given by Dr. Houghton, founded on many observa- 
inos t!^ '°® '^°}^ ^"^ ^«^^t^ aii'^ i'a disease, of specific gravities from 1003 to 
J.UZ8. ihe results are approximations to the daily excretion of urea in all 
cases where sugar and albumen are absent. The table is one of double entry 
and IS used by finding the daily excretion of urine in fluid ounces and its 
specific gravity by means of a carefully graduated urinometer. These data 
peing found, and the corresponding columns referred to in the table, at the 
intersection of the columns, the excretion of urea is given in grains. 

Ihe most opposite statements have thus been made regarding the amounts 

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260 



TOPICS RELATIVE TO PATHOLOGY. 



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TABLE FOR THE DETERMINATION OF UREA IN URINE. 261 






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262 TOPICS RELATIVE TO PATHOLOGY. 

of the excretions in fever, compared with the amounts excreted in health ; and 
at present many excellent observers hold that these excretions are always, and 
of necessity, increased ; others, no less exact, afBrm that they are invariably, 
or almost always, diminished. Such discrepancy of statement is due, in the 
first instance, to the difficulty of collecting and measuring exactly the amount 
of all the excretions. "Two of the excretions, the cutaneous and the pul- 
monary, cannot be collected and measured with anything like the accuracy 
necessary in such an inquiry: even in health such an inquiry is difficult, and 
in fever it is almost impossible." By careful and accurate observation at the 
bedside, however. Dr. Parkes has been able to obtain very close approxima- 
tive data to found his conclusions upon relative to the increase or diminution 
of the excretions. He assumes that when the respirations are not quickened 
(i. e., about eighteen times a minute, or about one act of respiration for every 
four beats of the pulse), and when the skin is not evidently sweating, the excre- 
tions by these two organs are not increased ; and, on the other hand, an in- 
creased excretion by these organs may reasonably be inferred if the exercise 
of their function is unusually active, and if there are tolerably copious per- 
spirations. The other two excretions — namely, the urine and intestinal dis- 
charges — can be measured with accuracy, and the urine in particular is a 
valuable index of the metamorphoses of tissue. The urea alone represents 
two-thirds of the whole quantity of nitrogen which passes off; the sulphuric acid 
(the sulphates of the food being accounted for) represents almost entirely the 
oxidation of sulphur ; and the oxidized phosphorus of the body passes out in 
great measure, though not altogether, as urinary phosphoric acid. Therefore 
a careful examination of the urine, and of the intestinal discharges, with an 
approximative estimate of the pulmonary and cutaneous excretions, give suffi- 
ciently extensive and accurate materials for the question at issue. 

The products excreted are thus of such a kind as to be eliminated, some by 
the lungs, sorne by the skin, some by the bowels, and some by the kidneys, and 
rarely by two or more modes of excretion; for when the discharges from the 
skin or bowels are profuse, those by the kidneys are deficient, as in the last two 
cases recorded in the following Table I, in which the augmented excretions 
are printed in italics. The facts thus so carefully observed by Dr. Parkes, 
confirmed by Alfred Vogel, Heller, and others (but chiefly in regard to the 
excretion of urea only), justify the conclusion — "That increase of temperature 
may be attended with increased elimination; and therefore premmably vAih 
increased tissue-change." 

The abstract given in Table II shows that another conclusion is equally 
legitimate, namely, — " That the products of metamorphosis, as judged of by the 
excreta, may be diminished in febrile cases. These statements, apparently dis- 
cordant, are capable of explanation in various ways. In the first place, it is 
evident that more chemical change may go on in the body than is represented by 
the excreta. The metamorphosis of blood or of tissues may not be carried to 
•thepoint of forming those principles which can alone pass through the elimi- 
nating organs. A vast amount of imperfectly organized compounds may be 
formed and retained in the system, circulating with the blood or thrown upon 
certain organsJ' Thus there may be increased metamorphosis with lessened elimi- 
nation. Several pathological facts point to such a conclusion. • 

1. It is in such febrile cases, with diminished excreta, that, at a later period 
of the disease, copious discharges from one or other of the eliminating organs 
occur. Thus, in the case of pneumonia referred to in Table II, severe spon- 
taneous diarrhosa came on; and many other cases are quoted, with similar 
diminution of the excretions at the period of increased febrile heat, in which 
violent purging, sweating, or diuresis, with increase of urea and of sulphuric 
acid, subsequently occurred. Such discharges occurring during the progress 
and towards the termination of a febrile disease have been termed critical, the 
occurrence being called a crisis; and the particular day on which it happens, 



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RELATION OF EXCRETA TO FEVER-HEAT. 



263 



counting from the day of seizure, has been called a critical day. The term erids 
or critical is applied because the occurrence of such discharges is usually coin- 
cident with more or less sudden fall of temperature, and general improvement 

Table I. — Abstract op Cases in -which some of the Excretions are 
Increased in consequence of the Febrile State (Dk. Parkbs). 



Disease. 


Average 

Temperature 

above 98°. 


Condition of 
Pulmonic 
Function. 


Condition of 

Cutaneous 

Function or 

Sliin. 


Condition of 
Intestinal 
Function. 


Conditioi) of Urinary 
Excretion, 


Eheumatism 


Fahr. 3°. 


Not noted. 


Sweating 
profusely. 


Discharge 
as usual 


Solid matter excre- 
ted greater than in 
health by 100 grains, 
and due to urea and 
sulphuric acid. 


Rheumatism. 


Fahr. 3°. 


Not noted. 


Sweating 
profusely. 


Discharge 

not 
diminished 


Solid matters excre- 
ted greater than in 
health by 200 grains, 
and due to area and 
sulphuric acid. 


Typhoid 
Fever. 


Several 
degrees. 


Rapid. 


Moist. 


Not . 
increased. 


Increased by 60 
grains. 


Erysipela^s of 

Head and 

Face. 




Quick. 


Moist. 


Unaltered 


Considerably 
augmented. 


Febricula. 


Fahr. 3°. 


Normal. 


Enormously 
augmented. 


Confined. 


Solids less than nor- 
mal by 91 grains. 


Typhoid. 


Fahr. 3°. 


Not noted. 


Sweating and 
Sudamina. 


Diarrhoia 
profuse. 


Solids less by 73 
grains. 



Table II. — Cases in which there "was Diminution of the Excretions (Dr. 

Parkes). 



Disease. 


Average 

Temperature 

above 98°. 


Condition of 
Pulmonic 
Function. 


Condition of 

Cutaneous 

Function or 

Skin. 


Condition of 
Intestinal 
Function. 


Condition of Urinary 
Excretion. 


Bronchitis 
of both 
Lungs. 


Fahr. 2. 6°. 


20 Respira- 
tions per 
minute. 


Not 
increased . 


Not 
increased. 


Less by 112 grains. 


Pneumonia. 

Acute 

Sthenic. 


Fahr. 5°. 


30 per 
minute ; ex- 
pectoration 

scanty. 


Slightly 
moist. 


Confined. 


Less by 220 grains. 


Typhoid 
Fever. 


Consider- 
able. 




No sweating. 


_ No 
diarrhoea. 


Below normal 
amount. 


Acute 
Rheumatism. 


Fahr. 4°. 


Tranquil 
breathing. 


Inconsider- 
able. 


Bowels 
quiet. 


Very small amount 
of urinary solids. 



m the condition of the patient, whose convalescence dates from the critical 
day; when, in common language, his disease is said to have "got the turn." 



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264 



TOPICS RELATIVE TO PATHOLOGY. 



In such cases, therefore, a large amount of partially metamorphosed substances 
are retained until they are suddenly discharged, and the system freed from 
the noxious compounds. Coincident with the critical discharge, the tempera- 
ture is found to fall. 

Table III. — Table of Cases to show Local Lesions coincident with 
Sudden Eetbntion of the Excketions in Fetbk {Or. Parkes). 



Disease. 


Average 
Tempera- 
ture 
above 98°. 


Condition of 
Pulmonic 
Function. 


Condition of 

Cutaneous 

Function or 

Skin. 


Condition of 
Intestinal 
Function. 


Condition of Urinary 
Excretion. 


Bheumatic 
Fever. 

Observed 
on the 

5th, 6th, 

and 7th 

day of the 

disease. 


Fahr. 2°. 
Fahr. 2°. 


No record. 


, Sweating 
profuse. 

Lessened on 
the 8th day. 


No intestinal 
discharge. 


While 400 grains 
more than in health 
were being daily ex- 
creted, suddenly on the 
8th day a diminution 
of the solids took place 
by 602 grains ; and 
coincident with this 
diminution a local le- 
sion became developed 
{angina faucium). The 
next day the excretion 
augmented, and the lo- 
cal aifection subsided. 


Typhoid 
Fever. 


Fahr. 5°. 
Fahr. 5°. 


No record. 


Great 
sweating. 

Lessened 
much. 


Diarrhoea 
profuse. 

Diarrhoea 

ceased. 


"While the average 
daily excretion for 8 
days was 422.348 grs., 
a gradual diminution 
continued for 3 days, 
to the daily extent'of 
78 grains, when pleu- 
risy came on. 


Bheumatic 
Fever. 




No record. 


Sweating 
moderately. 


Unchanged. 


Considerable quan- 
tity of urine passed, 
containing an exdess of 
solids : a sudden and 
great diminution both 
of the solids' and fluids 
of the urine took place, 
when the joints again 
began to suffei', and 
pleurodynia super- 
vened. 



2. But in another class of febrile eases, retention of the products of meta- 
morphosis is not followed by such a fortunate critical issue. At a later period 
in the history of some febrile cases, with diminished excreta, it is not uncom- 
mon for secondary inflammatory affections to occur, as if the blood were more 
contaminated ; and it is sometimes observed that in a patient whose excreting 
organs are acting copiously, that there occurs a diminution of excretion when 
a simultaneous or subsequent development of local disease becomes manifest. 

The preceding Table of Cases is interesting from the exactness of the obser- 
vations and the coincidence of the local lesions with suppression and retention 
of excreta during febrile states. 

• 1^^^^ ^* ^^ evident, from these carefully recorded observations, "that dimin- 
ished excreta in fever are to he referred to retention of such excreta, and not to a 
want of formation; and that while the amount of excreta {capable of bdng 



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RELATION OF EXCRETA TO FEVER-HEAT. 265 

measured) may in fact be small, the anwunt of tissue-change may nevertheless he 
great. The practical lesson so often insisted on by the older physicians — 
"never to lock up the excretions,"— is thus demonstrated with scientific exact- 
ness. Another general and practical conclusion is, that the febrile heat cannot 
be measured even by the amount of the excretions as a whole, nor yet by any 
ingredient of them in particular; but must be estimated in correlation with 
them and with age and body-weight. Under the same degree of animal heat 
and in the same disease, different patients pass very different quantities of 
urea, uric acid, sulphuric acid, phosphoric acid, cutaneous and intestinal excre- 
tions. The same observations may be made regarding men in health. No 
two persons pass exactly the same amount of excretory products. 

The nature of these excretory products shows that it is the albuminous or 
nitrogenous tissues of the body which are being destroyed in the febrile state • 
for the excretory products of the urine are the representatives of the azotized 
structures. The amount of these excretory ingredients varies considerably 
trom day to day in fever exactly as in health. Often there is a regular gra- 
dation of increase and decrease: the urea, for instance, may, for two or three 
days, slightly but regularly diminish in amount, and then suddenly augment 
to Its highest point, again slowly to fall. The same fact may be obseryed 
with the sulphuric acid; and Dr. Parkes is led to believe that, both in health 
and m disease, a certain periodicity, having a range of three or fiye days is 
connected with these gradations of increase and diminution. ' 

The largest amount of urea excreted in twenty-four hours in the febrile 
state IS recorded of a case of pyaemia by Alfred Vogel, namely, 1235 grains 
Ihe largest amount observed by Dr. Parkes was in a case of typhoid fever in 
which It amounted to 885 grains. The largest amount of sulphuric acid'ie- 
corded by the same obseryer, when no medicine was taken, was in a ease of 
rheumatic fever. It amounted to 52.668 grains; and under the influence of 
liquor potassse m the same disease, he has known this excretion rise to 70 
grains— more than twice as much as in health. The largest amount of uric 
<mid excreted during a febrile disease in twenty-four hours, as recorded by 
Drs. Parkes and Garrod, has been 17.28 grains. 

"The amount of tissue destroyed in order to furnish such qutotities of 
excreta must be enormous; and if it is recollected that little or no food is 
taken by the feverish i^atient, and, therefore, that no materials are supplied 
tor the reconstruction of the textures thus melting away, three times more 
quickly than in health, the rapid loss in weight in fever, and the impaired 
nutritive condition of every organ at its close, will be at once evident." 

It is not yet determined where the increased destruction of the albuminous 
textures takes place; that is, whether it occurs in the blood or in the organs 
themselves. It is only known that both the albumen and the red corpuscles 
ot the blood_ are lessened in amount at the end of a febrile disease; and of 
the various tissues none appear to waste so fast as the muscles, and especially 
the involuntary ones (e.g'., the heart in typhus fever). The fat of the body is 
rapidly absorbed m fevers; and Virchow asserts that the bones also become 
iigMer While it is known that much of the metamorphosis of these tissues 
takes place m the normal way, it is also probable that there is an unhealthy 
or perverted metamorphosis which leads to the appearance of compounds in 
the excretions, either altogether foreign to the body or foreign in respect of 
place and time. There is evidence of this in the peculiar smell of the perspi- 
ration, in the peculiar coloring matter of the urine, as well as in the occasional 
excretion by it of hippuric as well as of lactic, valerianic, and other organic 

Next to the occurrence of preternatural heat in fever, the excessive retention 
oj water m the febrile system is perhaps the most remarkable and constant 

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266 TOPICS RELATIVE TO PATHOLOGY. 

phenomenon. Notwithstanding the large amount of water frequently taken 
to quench the extreme thirst, the quantity of the urine is lessened, and is eveu 
scantiest when the skin is driest. The "concentration of the urine which 
results, appears to be almost as good an index of the amount of fever as the 
temperature itself." The excretion of water by the skin is also, as a rule, 
diminished ; and it is a well-known clinical fact that the skin is drier than 
usual in febrile affections. Very early in the febrile state the buccal mucous 
membrane also becomes sticky, and the amount of saliva diminishes ; and the 
decrease in the quantity of the gastric fluid during fever has been proved by 
the well-known experiments of Beaumont on Alexis St. Martin. The intesti- 
nal juices, like the gastric, are also probably diminished, for the stimulus of 
food is taken away, constipation prevails, and the fseces are dry (Parkes). 

This retention of water in the system cannot at present be explained ; but 
Dr. Parkes has suggested that it may possibly be due to the presence in the 
blood (or tissues generally) of some intermediate waste product of the febrile 
body, of some substance which (like gelatine) has a powerfiil attraction for 
water. 

Besides water, there is reason to believe that chloride of sodium is retained 
to a certain extent in fever, or that it passes off less, readily with the urine; 
but much has yet to be learned of the nature of fever from investigations 
regarding the chemistry of the excretions, of the secretions, of the hlood, andof 
the organs. 

The Urine in Fever — The general characters of this excretion proper to 
the febrile state are, deficiency of water, increase of solids, if they are not 
retained, and especially of the urea, the uric, the sulphuric, the phosphoric, and 
the hippuric acids. The pigments also are increased; and the chloride of 
sodium is diminished. The deep color of febrile urine has usually been attrib- 
uted to its concentration ; but if febrile urine be diluted to the usual amount 
of fluid contained in healthy urine, it is still darker than normal urine. The 
coloring matter has been shown by Vogel to be increased sometimes fourfold, 
and it appears to contain more carbon than usual. This coloring matter in 
febrile urine is peculiar, and does not give any of the reactions of the bile- 
pigment. It may, according to Dr. Parkes, be considered as a measure of the 
metamorphosis of the blood-globules, which in some cases may thus be four 
times as rapid as in health. 

Another important fact connected with the chemistry of the urine in fever 
is the augmentatio7i of its free acidity, as measured by its neutralization with 
soda. 

The Blood in Fever. — The most trustworthy and interesting facts connected 
with the chemistry of the blood in fever are, — (1.) A diminution of the alka- 
line salts, as shown by Becquerel and Rodier in inflammation ; (2.) A dimin- 
ution of alkalinity of the serum, as shown by Cohen; (3.) The diminution of 
the albumen after the fever has lasted for some time, with a commensurate 
increase in the water of the serum ; (4.) A diminution in the numbers of the 
red corpuscles of the blood; (5.) In certain specific fevers the presence oturic 
acid has been detected; for instance, in the fever of rheumatism, by Dr. 
Garrod. 

Of the Pulmonary Excretion, in the febrile state, little is known. Some 
have found the carbonic acid augmented, others have found it diminished. 
Dr. Wilks, of Guy's Hospital, found that the ratio of respirations to the pulse 
is always increased, and that the pulse may be descending while the respira- 
tion remains high. Such phenomena he considers indicative of a positive 
increase of function of the lungs. 

It is important to determine when the blood becomes affected in fever. It 
has been, and still is, a favorite opinion to refer the origin of fever to primary 
disease of the blood ; and in almost all general (specific) diseases a fever- 
making cause appears to enter the blood; at least, writes Dr. Parkes, it may 



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, CONDITIONS PRODUCING THE PHENOMENA OF FEVER. 267 

be proved to enter in several cases ; and a strong analogical argument can be 
maintained as to its entrance in others. The fever-making cause also repro- 
duces itself in the blood, or in some organs ; and it is now generally admitted 
that the first action of the febrile cause is on the blood. 

The Nervous System seems to play so important a part in fever that Vir- 
chow, in his definition, states that the essential phenomena must have their 
immediate cause in changes of the nervous system. 

It is very difficult to substantiate this position, but the following general 
results prove the great influence ,of the nerves in febrile affections. Taken 
individually, they, no doubt, will impress different minds with different de- 
grees of force, while, collectively, they cannot fail to furnish an argument in 
favor of the essential participation of the nervous system in fever : 

1. There is the generally received physiological law, that nerves regulate 
the metamorphosis of tissue and the production of heat, both of which are 
altered in fevers (Helmholtz, Ludwig, Beenaed). 

2. There are those experiments on the vagus nerve which bring about 
febrile phenomena, such as increased cardiac action, pulmonary congestion, 
anorexia, and nausea (Bernard, Pavy). 

3. There are those arguments derived from the various symptoms which 
announce, accompany, or terminate fever, (a.) The remarkable depression, 
apathy, sense of exhaustion and debility, which usher in the febrile state. (6.) 
The shiverings, the contraction of the superficial vessels and of the skin, (e.) 
The increased rapidity of the heart's action, and the relaxation of the vessels, 
which soon follows the stage of contraction just noticed, or occurs without it. 
(d.) The congestion of the lungs, (e.) The periodicity of some of the phenom- 
ena of fever, and the occurrence of death or recovery on so-called critical 
days. (/.) The abnormal state of the secretions. 

4. The fearfully rapid death which sometimes ensues in the early stage, 
from some unknown cause, may with justice be referred to profound nervous 
lesions ; for there is great prostration, a galloping and early-failing pulse, and 
an excessively rapid respiration. 

5. The effect of certain remedies, such asv quinine, upon periodical febrile 
phenomena. 

Conditions which combine to produce the Complex Phenomena of Fever. 
— 1. The entrance into the blood of a morbific agent, and the alteration, of 
the blood to a certain extent under its influence, come first in the order of 
events. Perhaps this occurs under the incubative period, when often there is 
no rise of temperature, no fever ; that is, when no appreciable alteration of 
the general health can be discovered. The nature of the change in the blood 
is unknown. 

2. When the change in the blood has reached a certain point, the nervous 
system, or rather that part especially connected with nutrition and organic 
contractility, begins to suffer changes in composition, which probably paralyze, 
impede, or destroy the normal molecular currents. When this occurs, the ner- 
vous symptoms of weakness, depression, rigors, contraction of some parts and 
vessels, speedily followed by relaxation, mark the stage of invasion. 

3. Various parts, simultaneously, especially the muscles, and probably some 
of the organs, deprived in greater or less degree of nervous influence, begin 
rapidly to disintegrate, and by their disintegration preternatural heat is pro- 
duced. Little or no fresh material is assimilated to compensate for the loss ; 
great muscular prostration ensues ; and destruction of tissue is increased by 
the accelerated action of the heart. 

4. This metamorphosis is aided, in most cases, by the condition of the vagus 
and vasi motor nerves, which cause increased action of the heart and dilata- 
tion of the vessels. 

_ p. The contamination of the blood, already produced by the morbid agent, 
IS mcreased by the check which the normal extra- vascular currents experience,. 

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268 TOPICS RELATIVE TO PATHOLOGY. 

by the pouring into the blood of the rapidly disintegrating tissues, and by the 
continued action of the morbid agent, which in almost all cases appears to act 
more rapidly and more powerfully in blood rendered impure in any way, 
either (as shown by Dr. Carpenter) by retention of excretions, absorption of 
septic substances, or; as in fever, by the too rapid metamorphosis of tissue. 

6. The various organs suffer (apart altogether from specific changes), and 
must produce increased deterioration of the blood. Thus the lungs are con- 
gested in so many cases that we can scarcely suppose proper aeration to go on ; 
the liver would seem, from Frerichs's observations, to be, in some cases at any 
rate, in a most abnormal condition, and to produce compounds (such as leudn) 
unknown in health ; and the spleen in many fevers, if not in all, enlarges (in 
persons of a certain age), and is congested, possibly even to extravasation. 

7. Food being almost withdrawn, the various alkaline and neutral salts no 
longer pass into the system. 

8. Non-elimination of the products of tissue-metamorphoses may give rise to 
cerebral symptoms and local inflammation. 

9. On the elimination of the fever poison and of the products of the tissue- 
metamorphoses, the nerves resume their normal fimctions, the undue consump- 
tion of tissue is checked, and the patient regains strength and weight. 

10. When coma, delirium, or stupor present themselves in the course of 
fever, it is the custom to refer these symptoms to the action of the fever poison 
on the brain ; but the cerebral functions are more probably deranged not alone 
by the fever poison (which was the first and the necessary link in the patho- 
logical chain), but by the accumulation in the blood of the products of tissue- 
metamorphosis, and by the perverted and defective nutrition of the brain 
itself. Hence the symptoms in the advanced stage of many fevers are closely 
assimilated, although the primary poisons have been perfectly distinct (Paekes, 
Murchison). 

All these events tend to render the febrile state an extremely complex one, 
and its investigation difiicult. Our science is often spoken of as an exception 
to the exactness or comparative certainty of the (so-called) physical sciences ; 
but nothing can demonstrate more clearly the claims of the Science of Medi- 
cine to exactitude and certainty than the advances made in recent years in 
our knowledge of the natural history of febrile diseases — ^their causes, their 
modes of propagation — their development, natural course, and termination. 
Improved methods and instruments of research, with more extensive clinical 
instruction at our schools of medicine, have contributed to this end ; and per- 
haps nothing demonstrates this exactness and certainty better than the ad- 
vances made in our knowledge of the thermometry of disease, and the correlation 
of body-heat with other morbid phenomena. By numerous careful observa- 
tions it is now clearly established that the determination of the correlation of 
the pulse, the respiration, and the temperature of the body, is of the greatest 
practical importance, and especially when regarded in relation to the amounts 
of excreta. By such observation the natural course and termination of many 
diseases can be predicated with great certainty ; and so our knowledge becomes 
more exact as to their nature and treatment. The pulse, the respirations, and 
the temperature, all and each of them, represent forces at work in the living 
body, all of which are capable of being measured with great exactness ; and 
such measurements show how closely such expenditure of forces is related to 
the excreta, which represent the waste of our tissues in health and disease. 
The student or physician who continues to disregard the aid of thermometry 
in the diagno^ of febrile disease, or the military medical ofiicer who ignores 
its value in the appreciation of feigned diseases, may be compared to the blind 
man guiding himself. By means of great practice and intelligence, the blind 
man will often proceed rightly ; but the advantages of being able to see clearly 
are proverbially above all price. The necessity of using the thermometer will 
also soon become known to the general public, and patients will become dis- 



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TYPES OP DISEASE AND THEIR TENDENCY TO CHANGE. 269 

satisfied, if all known means of investigation are not employed in appreciating 
the nature of their malady. For many years the German student and physi- 
cian has been familiar with its use ; but, until Dr. Parkes, and the pupils he 
taught when Clinicar Professor in University College Hospital, began to use 
the thermometer, its usefulness in recognizing febrile diseases does not seem 
to have been hitherto sufficiently appreciated in the medical schools of this 
country. The author is pleased to learn, from the numerous communications 
he receives, that this chapter, in previous editions, has led many to use the 
thermometer invariably in clinical work ; and within the past two years (since 
1868), the use of the thermometer in practice has steadily increased. 

Before stating the principles which ought to guide the treatment of the va- 
rious complex morbid processes described in the previous pages, and of indi- 
vidual diseases in particular, it behooves the student, first, to make a separate 
study of the varying types of disease, their prevailing peculiarities, and the eon- 
stitidional tendency to change of type which they assume at varying intervals of 
time ; and, second, to observe and learn to recognize the various modes by 
which diseases terminate fatally. 



CHAPTER IX. 

TYPES OF DISEASE AND THEIE TENDENCY TO CHANGE. 

Definition. — The type or foem of disease is the order of succession observed 
to obtain among certain morbid phenomena ; and admits of modification from 
various causes, without the intrinsic nature of the phenomena being essentially 
affected (Copland). 

In describing, appreciating, or ascertaining the type of a disease, our atten- 
tion must be directed to a variety of phenomena and conditions ; and the type 
of the disease only becomes characteristic and distinctive when some one or 
other of those conditions becomes predominant, or manifests itself more de- 
cidedly than others. The hereditary or natural constitution of the individual 
may be regarded as an important element in determining and modifying the 
type of the disease. Town life, as compared with country life, also exercises 
an infiuence in modifying the type of many diseases ; and there are good 
grounds for believing that the town life and artificial habits of the present 
period are more prejudicial to the strength of the constitution than those 
which prevailed when large towns were but rural villages, and the inhabitants 
more simple in their mode of life, and less artificial in their habits. 

The occupation of the individual in many instances exercises an influence 
over the complex processes of disease ; and there cannot be a doubt that some 
diseases have altogether disappeared, while others have been so much modi- 
fied that their resemblance to the original form or type can with difficulty be 
recognized. 

With regard to Edinburgh and its vicinity, Professor W. T. Gairdner 
observes that the changes of type which have occurred in epidemic fever, and 
especially in typhus fever, during the ten years previous to 1 862, or since the 
cessation of the great epidemic of 1847-8, are not less remarkable than the 
dirainution in the amount of this class of cases. The relapsing fever or synocha, 
which formed so large a part of the epidemics of 1843-4 and 1847-8, has for 
the time absolutely disappeared ; and in 1870 it again reappeared in several 
places (especially London) as an epidemic. Typhus fever has become less 
fatal to those attacked than it was from 1843 to 1848 ; while its general type 
and some of its leading characters have been remarkably modified. This is- 
especially noticeable in the diminished mortality ; the earliness of the appearance 

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270 TOPICS RELATIVE TO P-ATHOLOGY. 

of the eruption; the earliness of the crisis (tenth to fourteenth day as a rule, 
and rarely prolonged into the third week) — a great cause of the" diminished 
mortality ; for a day's delay of the crisis, in a case of any degree of severity, 
is an immense addition to the risk ( Clinical Medicine, 1862, p. 156, et seq.). 
Nevertheless, it is the rule that diseases preserve their essential characters and 
nature from age to age, although the opinions of the profession respecting 
them and their treatment may change from year to year, or from one period 
of time to another. For example, smallpox, measles, typhus fever, typhoid or 
intestinal fever, dysentery, diphtheria, and the like, always remain the same as 
to their essential characters, and unchanged in their special symptoms ; but it 
must be remembered that they are also very often modified in their phenomena 
by the exiatence of such constitutional ill-health (cachexia) as may arise from 
syphilis, mineral, vegetable, or alcoholic poisoning of the system, as well as from 
gout, rheumatism, scrofula, tuberculosis, and scorbutus; also from epidemic 
causes, and especially also by the artificial mode of life in towns, as compared 
with the more natural habits of rural villages. These are the diseases and con- 
ditions of existence which are the main sources of deterioration of the human 
race, in all physical attributes, among such civilized communities as our own. 

Diseases also have arisen which appear to be more or less new to us, in 
some instances resulting from a hybrid combination of various pathological 
phenomena to be noticed presently. While this is undoubtedly the case, 
there is abundant evidence to prove that we now have in some respects a more 
healthful enjoyment of our life (although the constitution may not be so 
strong) than formerly ; and that the duration of man's life of late years has 
been prolonged. While it is the lot of " all men once to die," that final 
change is more frequently deferred than was wont, to beyond that period when, 
in the words of the inspired Psalmist, it is recorded that " the days of our 
years are threescore years and ten ; and if by reason of strength they be four- 
score years, yet is their strength labor and sorrow." 

It has been observed by a popular writer that there never were any specifics 
discovered against the plague, the sweating sickness, or the leprosy ; and yet 
these diseases, so far as regards this country, are now amongst the things that 
were, and are almost unknown. They have disappeared, not before any mar- 
vels of medicine, or any perfection of chemical science, but as a consequence 
of the gradual amelioration of the conditions of our mode of life through sani- 
tary improvements. Observe, also, what sanitary science has done, in a com- 
paratively short space of time, to ameliorate the condition of the British army. 
The Right Honorable the Secretary of State for War (the late Sir George 0. 
Lewis, Bart.), in moving the Army Estimates for the year 1862, in the House 
of Commons, said : 

" Improvements have been introduced with a view to ameliorate the social, 
moral, and sanitary condition of the private soldier. Much expenditure has 
been incurred for the sake of enlarging and improving barracks, and in car- 
rying out various recommendations of the House of Commons with respect to 
barracks and the hospitals connected with them. I am happy to say," con- 
tinues the Right Honorable gentleman, " that these efforts have not been un- 
attended with important results, as will appear from authentic returns of the 
mortality in the service. These returns have been prepared by the Director- 
'General of the Army Medical Department, and I believe they are perfectly 
.authentic, though it is certainly difficult to believe that so great a change can 
have taken place in so limited a period. It is possible that the greaiter youth 
•of some portions of the army may, to a certain extent, affect the returns, but 
I believe the difference is mainly to be explained by improvements in the 
sanitary conditions under which they are now called on to serve. 



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RESULTS OF SANITARY SCIENCE. 271 



" Deaths among the Troops skeyinq in the United Kingdom annually per 

lOOO OF Men. 

From 1830 to 1836. 1859 to 1860: 

Generally throughout 14 ... 5 

Cavalry of the Line, ..... 15 ... 6 

Koyal Artillery, 15 ... 7 

Foot Guards, 21 ... 9 

From 1836 to 1846. 1859 to 1860. 

Infantry of the Line 17 ... 8 

"Similar Returns eor the Colonies are as follows: 

From 1837 to 1856. ■ _ 1859 to 1861. 

Gibraltar, 22 ..." 9 

Malta, 18 ... 14 

Ionian Islands, 27 ... 9 

Bermuda, 35 ... 11 

Canada, 20 ... 10 

Jamaica, 128 ... 17 

Ceylon, 74 ... 27 

" I have other returns from other colonies," continues the Right Honorable 
gentleman, " and I believe that these returns are authentic ; and certainly 
they show how very considerable a diminution has taken place in the mor- 
tality of the army" (Times, March 4, 1862). 

The late Lord Herbert was the main agent in accomplishing this great 
work, which, as years pass on, will become better appreciated, more widely 
known, and more energetically followed up. 

Professor W. T. Gairdner has happily observed, that in proportion as we 
are getting rid of the severer forms of epidemic disease (e. g., fever, dysentery, 
scurvy, influenza, all more or less preventible), which had deteriorated the 
health of the population previously to 1848, we are also getting rid of the 
more severe and unmanageable types of acute inflammation. Inflammatory 
diseases, like fevers, he therefore justly considers to be subject to epidemic 
causes of increase and diminution, both as regards frequency and severity ; 
and he believes that the acute inflammations are nearly as much under the 
influence of the sanitary reformer as the more obviously epidemic fevers; and, 
fiirther, that some even of the chronic organic diseases have already yielded, 
and may be expected still further to yield, to the improved habits, the better 
clothing, the greater abundance of food, and the diminished destitution of the 
population generally {Clinical Medicine, p. 42). 

The Art of Medicine, guided by Sanitary Science, must now, therefore, be 
regarded as a productive art ; for, by diminishing the occurrence of preventi- 
ble disease, and thereby lessening mortality, the average duration of human 
life has been extended to an age nearer that which has been ordained for man. 
Nevertheless, it behooves the physician to remember that the sphere of his 
professional exertions is limited, and surrounded by insurmountable barriers ; — 
that death will eventually come alike to all, " reminding us that we ourselves 
must become victims to the incompetency of our art." 

Dr. Pollitzer, of the Children's Hospital at Vienna, has expressed the opin- 
ion, that while the duration of mortality at early ages is diminishing in all 
civilized countries, under the various influences of extended hospital accom- 
modation, care of the sick, vaccination, and general sanitary regulations, there 
is no corresponding increase in the strength and vigor of the human race. On 
the contrary, the boundaries between health and disease are becoming less and 
less marked. There are now to be observed numerous conditions which are 
undoubted deviations from the healthy standard, which it is impossible to 
delineate or accurately to define, because they make their appearance during 
_ a state o{" relative health." The physician is not always even able to name 

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272 TOPICS RELATIVE TO PATHOLOGY. 

the disease ; and while the patient maintains that he is not feeling in health, 
and not looking in health, but wasting away, his food doing him no good, he 
has no alternative but to call himself ill. Such is the insidious mode in which 
many of these truly constitutional diseases, which have yet to be described, 
and DEGENEEATiONS whicli have been already described, make their appear- 
ance, and which may be regarded as constituting a peculiarly characteristic 
feature in the diseases of our times. These conditions are known by the various 
names of ancemia, sparwBmia, leucoaythwmia, chlorosis, to which we must also add 
such degenerations as those described in the previous pages, namely, lar4a- 
ceous degeneration, pigmentation, fatty degeneration, and the ill-health (ca- 
chexia) of malaria and of syphilis. 

The poorness of the blood, peculiar to the class of diseases mentioned, 
furnishes the soil in which the feebleness and deterioration of race is most 
unmistakably evident. The nervous system is, moreover, extensively involved 
in the diseases of the age. Feebleness and debility constitute a dominant 
characteristic of the prevailing type of disease. This physical deterioration is 
held to be a " sad memorial of modern civilization." In this respect the obser- 
vations of Dr. PoUitzer coincide with those of Dr. Forbes Winslow. "A con- 
stant stretch of the mental powers, a restless excitement of the passions, a per- 
petual struggle for advancement, the fresh wants of every day (science, and 
the arts themselves, being subservient even to the luxury and demoralization 
of the times), the destruction of all moral harmony and peace, are evils which 
undoubtedly prevail, and which react especially upon the younger genera- 
tion." The sins of the fathers are thus being visited upon the children. The 
demands made upon the youth of eighteen or twenty of the present day, by 
competitive examinations on the one hand, and rapidity of work on the other, 
would formerly have been considered a sufficient tax for the strength of a man 
of upwards of five-and-twenty. It is the pace that kills. Many features, also, 
which characterize the pathology of our age have arisen out of the treatment 
of infancy and childhood ; and much of the deterioration of the race at large 
may be shown to date its origin from infancy. Thus, after seventeen years' 
observation in children's disorders, Dr. Pollitzer writes, that ancemia and chlo- 
rosis occur alone or associated with rickets, hypertrophy of the lymphatic glands, 
and of the spleen and liver, to an incredible extent even from the first month 
of life. In the children's hospital at Vienna, from seventy to eighty per cent, 
he found to be thus affected. Wherever the nutrition of the child had been 
imperfect, the constitutional diseases associated with poverty of the blood 
became widely diffused. The stomach and intestinal tract first suffer, consti- 
tuting the prevailing morbid condition of childhood — materially influencing 
the mortality at an early age, and if the age of childhood is survived, affect- 
ing the future health of youth and manhood, and doubtless of subsequent gen- 
erations (Med.-CUr. Review, Report on Medicine, p. 261, July, 1857). 

The types of disease are also evidently modified by complication with other 
diseases, now more widely spread. The doctrine of the incompatibility of two 
or more contagious diseases concurring in the same subject has been clearly 
proved to be erroneous ; so that one form of disease complicates or overlays 
another in a manner that at one time was not thought of Dr. Murchison, in 
an admirable paper on this subject in the British and Foreign Medico-Chirur- 
gical Review for July, 1859, has clearly shown the coexistence of variola and 
scarlatina; also of variola and rubeola. Dr. F. J. Brown, of Eochester, has 
recorded a case of variola concurring with measles and purpura. The coexist- 
ence of variola and roseola or erysipelas, of variola and pertussis, of variola and 
varicella, of variola and vaccinia, of vaccinia and scarlet fever, of vaccinia and 
rubeola, of vaccinia and pertussis, of vaccinia and varicella, of rubeola and per- 
tussis, of variola, rubeola, and pertussis, of scarlatina and rubeola — ^the rotheln 
of the Germans — of scarlathm, and enteric or intestinal fever, of typhus and ew- 
teric, intestinal, or typhoid fever, have all been more or less clearly shown. 



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AGENCIES MODIFYING THE TYPES OF DISEASES. 273 

Virehow relates a case of typJioid fever, combined with striking symptoms of 
cholera, occurring at Wiirzburg. Typhus fever and the marsh fevers have been 
observed to occur together (Peingle). Bilious remittents have prevailed 
with small-pox in the West Indies, forming, as an old but outspoken writer 
remarks, "the most infernal combination that ever affected the human 
frame." Yellow fever has been found associated with putrid typhus; while 
specific yellow fever and marsh fever, with phenomena similar in many respects 
to specific yellow fever, undoubtedly occur together. 

There are good grounds for believing that as we approach certain well- 
marked geographical regions of the earth, where characteristic types of dis- 
ease prevail, the confines of these disease-realms are found to mingle their 
types of disease together, so that the diseases of one region merge into and 
participate iu many of the characters peculiar to the other. Cholera has 
extended its ravages over the earth, and is now a disease whose germs are 
endemic in our land ; and the system under its influence,, especially in the 
early cases of an epidemic, becomes rapidly depressed, to the speedy extinc- 
tion of life. The furuneuloid epidemic which prevailed about eleven years 
ago was one of a novel variety. The hlack death of the fourteenth century 
seems to have revived in India, and is described by the name of the Indian 
poll plague ; and it may be that the formidable disease which laid waste our 
country in the thirteenth century may have arisen in these districts, and pro- 
ceeded thence to our land, passing apparently in the same way that cholera 
has done (De. Allen Webb). 

Our modern treatises on medicine justly and properly deal, largely and 
minutely, with the descriptions of individual diseases, as far as their nature 
can be discerned ; and the languages of all civilized nations attempt to define 
and describe them clearly. Now only are we beginning to profit by an ex- 
tended inquiry into the diseases of nations ; and to find that as man wanders 
from his native home, the type of the diseases to which he is liable also 
changes. In this field of science an unmeasurable and still unexplored 
country extends on every side. The more minutely, also, that individual 
diseases can be defined and described, the more useful will such descriptions 
be for comparison in future ages ; and it will be seen, on comparing the de- 
scriptions of diseases in time past with accurate descriptions of the same dis- 
eases now, how, at various periods and under various circumstances, the 
expression of certain sets of symptoms becomes sometimes strongly developed, 
while at other times the same classes of symptoms were mild and subdued ; 
but the really essential characters of specific diseases and morbid processes 
remain as persistent as the specific characters of a plant or an animal. 

It will be seen how, in epidemics, many diseases have been characterized 
by the expression of malignant phenomena scarcely perceptible before. The 
small-pox nowadays is not the malignant small-pox of the time of Sydenham. 
Nevertheless, it is small-pox. And although it may be said that such an 
example does not illustrate a change in the type of a disease, because the 
change has been eifected by artificial means, yet it must appear evident that, 
in effecting this change, natural results have only been imitated ; and who 
can tell what modifying influences of a similar kind are going on, although 
the science of medicine can as yet take no cognizance of them ? We know 
that certain diseases confer immunity on the individual from future attacks ; 
may it not be, therefore, that immunity to individuals from some diseases is 
conferred by agents and processes of which we as yet know nothing ; and that 
ultimately the types of complex morbid states may still come to be very much 
changed from what they are now? They appear to be changed, according 
to the best authorities, from what they were fifty years ago. " Many of the 
symptoms, and particularly the constitutional fever usually attending internal 
inflammations, and resulting from cold, or from other causes independent of 
the application of morbific poisons, are liable to variation in like manner, 

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274 TOPICS RELATIVE TO PATHOLOGY. 

although not so decidedly nor so rapidly as the epidemic diseases, in the 
course of time, and from causes not yet known. They have in fact under- 
gone very considerable change since the early part of the present century" 
(Alison). 

Such changes in the types of diseases were formerly observed and much 
insisted upon by Sydenham, especially in the progress and recurrence of con- 
tinued fevers ; and it is now a fact well recognized, that not only does the 
prevalent mode of fatal termination during epidemic diseases vary, but so 
also do the types, peculiarities, and morbid constitutional tendencies vary in 
these diseases. It is chiefly with regard to the local, sporadic, or intri'iisic 
diseases, and especially inflammations, such as the cephalic, the pulmonic, or the 
enteric, that any doubt exists as to whether or not they vary in their type. 
Distinct statements as to this fact, however, have now been made by many 
accurate observers, whose experience is of the utmost value to science. Dr. 
Alison and Dr. Bennett both agree as to the fact, " that of late years, and 
apparently also in different parts of the world, inflammation, the most important 
of all forms of local -diseases, seldom shows itself with such general symptoms 
as demand or would justify, in the opinion of the practitioners treating them, 
or indeed could bear, the large bleedings which were formerly regarded as the 
appropriate remedy, and which accordingly are now seldom practiced." There 
are not only also fewer examples of violent inflammation of the lungs to be 
met with, but the usval (highly inflammatory) type of fever attending such 
inflammation has materially changed, as occurring in the present day. This 
change which has taken place in the type of the usual phenomena character- 
istic of inflammatory fever, cannot be explained merely by the circumstance 
that a previously enfeebled or diseased state of the system has brought it about 
in the individual. The inflammations of internal parts, such as pneumonia, 
now occur often without much febrile reaction, and neither demanding nor bear- 
ing full bleedings, as described by Cullen and other authors. It is consistent, 
moreover, with the extensive experience of Drs. Alison, Christison, Watson, 
and many other physicians of the greatest eminence and long experience, that 
inflammations now seldom occur with such severe symptoms of inflammatory 
fever as have been described at page 87, and which were the rule in the time 
of Cullen and of Gregory. The constitutional symptoms now attending such 
inflammations partake more of the type of the so-called typhoid state, and iade- 
pendent of any epidemic influence or poison having acted on the body. 

The constitutional symptoms for many years past accompanying pneu- 
monia, for instance, in this country, have been of the following kind: An 
enfeebled circulation ; softness of the pulse, and easiness of depression by 
depletion, or even by taking the erect posture; tremors and feebleness of vol- 
untary muscular motion, approaching to subsultus ; indifference to surrounding 
objects; sickness and vomiting in some cases, with dryness of tongue and lips 
in others ; complete anorexia or depraved appetite ; in all, the symptoms gen- 
erally tend to assume those of the so-called typhoid state rather than of infiaim- 
matory fever. Nevertheless, in the treatment of such cases, blood taken 
sufficiently early, if breathing is difficult, is distinctly beneficial ; and although 
it may show the buffy coat, this has neither the thickness nor the tenacity of 
the fine huffy coat seen and described in former days ; faintness supervenes on 
the loss of a quantity small in comparison of what was formerly well borne, 
and there is no such encouragement to a repetition of the bleeding, from the 
pulse speedily regaining its strength, or from the local symptoms abating and 
quickly recurring, as was formerly noticed by Cullen, Gregory, Christison, 
Alison, and other veterans in the practice of medicine. Dr. Gairdner also 
points out the_ great distinction to be drawn between the doctrines of Alison 
and cf Todd in this respect. Dr. Alison recognized the disuse of bloodlet- 
ting, and the increased necessity for stimulants, as a consequence of the changes 
he observed in the character of diseases. Dr. Todd, on the other hand, dis- 



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EXAMPLES OF CHANGE OF TYPE IN DISEASE. 275 

owned entirely the idea of such a change, and came to regard the adminis- 
tration of stimulants as a matter of routine. The former recognized the 
altered type of disease, the changes observed in its physiological manifesta- 
tions, and the gradual disappearance of those forms of acute inflammation 
which before had appeared to require and to bear bloodletting. Dr. Todd 
did not recognize or acknowledge these changes (^Clinical Medidne, 1862, 

P-34). 

The mode of fatal termination is also different. The tendency to death is 
most usually either by coma or by asthenia, as in typhus fever. The tendency 
to gangrene is said to have become more frequent in various inflammations of 
internal parts, and particularly in the lungs, within the last fifty years, than 
it was in the time of Cullen and of Gregory. Such are the records of expe- 
rience, as stated by the late Dr. Alison in a series of papers published in The 
Edinburgh Medical Journal in 1855, 1856, and 1857; than whom the opinion, 
of no one is more entitled to respect and consideration ; and, " although dead, 
he yet speaketh." 

Dr. Handfield Jones, physician to St. Mary's Hospital, London, observes, 
"that instances of impaired action of the heart, sometimes amounting ,to 
serious danger, are met with at the present time with an absence of all condi- 
tions which require or justify venesection. This is associated with other 
symptoms of depressed nervous power, which appear to be most reasonably 
attributed to some kind of epidemic influence much resembling that of mala- 
rious diseases." 

The type of disease which reigns at present is believed by some to have 
prevailed more or less since the appearance of pestilential cholera in 1832. 
■ There is now little of sthenic inflammation; bleeding and tartar emetic are 
but sparingly needed, while quinine, strychnine, and other tonics, with opium, 
and cod-liver oil, are continually in requisition in our efibrts to raise and 
maintain failing power {Medical Journal, March, 1857). According to the 
experience of obstetric practice, the observations of Mr. Sidey, of Edinburgh, 
are to the same effect. 

In 1782, when Dr. Hamilton published his memoirs on the " contagious 
catarrh," or influenza, he records distinctly his belief that " our constitutions 
are considerably changed within the last century in Great Britain. Diseases," 
he remarks, "in their nature phlogistic (e. g., measles'), have appeared within 
the thirty years previous to 1782 less inflammatory than they formerly 
were, and accompanied with a considerable degree of putridity ;" and blood- 
letting in the " contagious catarrh," he states with emphasis, cannot be toler- 
ated. There seems, therefore, to have been even then an increasing belief 
that the degeneracy of the human race, as a whole, was in some respects 
advancing ; and, that there seemed to be some visible evidence of this more 
or less traceable through the past four generations. 

Dr. Graves, in the course of an interesting and able argument .in favor of 
the change in type or constitution of disease, describes how the epidemic 
of influenza exhibited phenomena different from the typical phenomena of 
sthenic inflammatory catarrh. 

Morel especially directs attention to the apparent increase in Europe of 
mental alienation, and of those abnormal states of existence which have 
special relations with the occurrence and existence of physical and moral 
degeneracy in the world ; .and if a comparative increase in the number of the 
insane cannot yet be proven, there would seem to be a tendency to more fre- 
quent complications among them of those morbid states which diminish the 
probability of cure, such as general paralysis, epilepsy, and a marked depression 
of all the intellectual and physical forces, which depression is consistent with 
the asthenic phase of present existence. Hysteria and hypochondriasis, formerly 
almost the exclusive appanage of the rich, the indolent, and those of a wasted 

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276 TOPICS KBLATIVE TO PATHOLOGY. 

life, are known to attack in great proportions the working and the agricul- 
tural classes, among whom suicidal tendencies are also apt to prevail. 

Dr. Forbes Winslow writes, with regard to nervous diseases, that cases of 
disease of the brain and nervous system are now not only of more frequent 
occurrence, but that a certain unfavorable type of cerebral disorder develops 
itself in the present day at a much earlier age than was formerly observed. 
Softening of the brain, for instance, often manifests itself at the early age of 
thirty and thirty-five. The brain in the present day is overworked, its 
physical functions are unduly exercised, strained and taxed in the great 
effort required in the severe struggle and battle of life to obtain intellectual 
supremacy, professional emolument, and status (Journal of Psychological Medi- 
cine, July, 1857). 

Morel again shows how imbecility, congenital or early acquired idiocy, and 
other more or less complete arrests of development of the body, and of the 
intellectual faculties, indicate the existence of children who have acquired 
the elements of their degeneracy during intra-uterine life. It behooves, then, 
all civilized governments anxiously to inquire into and to consider such facts 
as show, — (1.) A continued increase of suicide. (2.) A continued increase of 
crimes against order and law, or against the person. (3.) The monstrous 
precocity of young criminals. (4.) The abnormal conformations of the skull, 
and tendency to early union of the cranial sutures, which prevail among 
criminals. So much is this the case, that in large towns, or in penal settlements 
and convict prisons, the physiognomy and general aspect of the " criminal 
population " are characteristic of a class, as their photographs show. (5.) A 
general diminution of the intellectual powers, with the manifestation of the 
most depraved immoral tendencies. (6.) An increase in the inmates of 
asylums and prisons. (7.) The etiolation, blanching, ansemic or cachectic 
condition of the population, and any relative increase of such constitutional 
diseases as ancemia, chlorosis, gout, Bright's disease, rheumatism, melituria. 
(8.) Any increased development of paralytic and convulsive affections. 
(9.) Prevalence of degeneration, as distinguished from diseases. These are the 
main directions in which the degeneracy of the human race is demonstrable; 
so much so, that in some localities the inhabitants can no longer fulfil the 
conditions required for military service (Traite des Degmerescences Physiques, 
Intellectuelles et Morales de I'Espice Humaine, el des Causes qui produiserd ees 
VariH'es Maladives. Par le Dr. B. A. Morel, de I'Asile des Alienes de S'Yon, 
1857). 

The principal sources of degeneracy which appear at present to be most 
active in their influence for evil on large masses of mankind may be stated as 
follows: (1.) Degeneracy from Toxasmia,, a,s irom the ahuse oi alcoholic fluids, 
opium, preparations of Indian hemp (hachisch), tobacco, and the like; also from 
the effects of mineral poisons, such as lead, mercury, arsenic, phosphorus ; aud 
from the use of unwholesome vegetable food, such as diseased rye, maize, 
wheat, and the like. (2.) Degeneracy from the persistent and pernicious 
influence of malaria. (3.) Degeneracy from certain peculiar geological for- 
mations, soil, and water, as in the development of goitre (Maclellan, Wat- 
son). See Paper on Hygiene of India, in Med.-Chir. Review. (4.) Degene- 
racy from the effects of epidemic diseases which now and then aSiict large 
populations, profoundly influencing the system, and engendering those morbid 
temperaments whose types are more fully expressed in the generations which 
follow the one that has suffered from such epidemic pestilences. Many of 
such-like epidemics act like toxic agents on the nervous system. (5.) Degene- 
racy from the effects of the " great town system," as the phrase is. The chief 
elements of such degeneracy are, (a) unhealthy situations; (b) a noxious 
local and general atmosphere ; (c) insufficient air ; (d) insufficient and im- 
proper nourishment ; (e) deleterious avocations ; (/) moral and social misery, 
wretchedness, and crime. (6.) Degeneracy from fundamental morbid states, 



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ACTIVE SOURCES OF DEGENEBACY. ■ 277 

congenital or acquired, as seen in the numerous malformations whose nature 
has been described at p. 233 et seq., imperfect cerebral developments, deaf mutism, 
blindness, constitutional diseases, and diathesis (implanted, hereditary, or ac- 
quired), such as syphilis and scrofulosis. (7.) Degeneracy from mixed causes, 
from marrying in and in ; and from other causes not included in the above 
{Med.-Chir. Review, Jan., 1858). 

_ By far the most active sources of degeneracy are thus seen to be those 
direct and repeated influences upon the blood, the brain, and the nervous system, 
which give rise to special morbid conditions; and which often place those who 
periodically expose themselves to the influence of toxic agents in a condition 
verging on or equivalent to insanity. The efiects of chronic alcolwlimi, for 
instance, in giving rise surely and progressively to the mental and bodily degen- 
eration of the individual, are mainly demonstrable by the induction of the 
following states, namely: persistent loss of appetite, indigestion, nausea; occa- 
sional diarrhoea, progressive emaciation, and cachexia; the appearance of 
pustular eruptions; the occurrence of eructations associated with ofiensive 
breath ; serious disturbance of the functions of the stomach, liver, kidneys, 
and heart, and the production of organic lesions in these organs, and in 
the structures of the bloodvessels, followed by fatal serous effusions, dropsy, 
hemorrhages, extravasations, or apoplexies. Intercurrent with these morbid 
conditions, there occur at variable periods, "fits of drunkenness," with 
sexual incompetency, different forms of psychical aberration, delirium tremeiis, 
suicidal melancholy, and such-like morbid phenomena. Finally, epileptiform 
seizures, general paralysis, drivelling or slavering idiocy, may close the scene. 
Those Mo become thus degenerate by alcoholic poison are arranged by Morel 
mto two classes, namely, —First, Individuals who arrive at length, by a series 
of well-marked nervous lesions— physical and intellectual— at general paral- 
ysis. Second, Individuals who, although profoundly affected as regards ener- 
vation, still remain stationary at a certain state, leading a miserable existence, 
characterized physically by a special condition of ill-health (cachexia and 
marasmus), and morally by a manifestation of the worst tendencies, and of the 
lowest animal propensities. The serious degenerative effects thus detailed in 
their extreme forms, resulting from the poison of alcohol, ultimately influence ' 
the procreative functions; first, by diminishing the vital standard of the 
offspring ; and second, by annihilating the generative power altogether. When 
such results are coupled with the moral and social aberrations which ensue 
from bad example, misery, and want, in families and masses of- men, they 
become ample sources of the degeneracy and degradation of the population, 
ihis they do, not only throughout the existing but succeeding generation; 
^M °°'' °^^^ ^® *^® ^^°® °^ alcoholic abuse thus hereditarily transmissible 
(Morel), but it also frequently leads to insanity in the offspring of the 
drunkard (Whitehead, Adams). In cases of this description, where the 
tendency to alcoholic excesses has a hereditary origin, the cure of the dipso- 
maniac is generally impossible. Morel gives the following example, in which 
a well-marked succession of morbid phenomena became developed in different 
descendants of a family throughout four generations. The great-grandfather 
ot the family was a dipsomaniac; and so complete was the transmission of the 
disease, that the race became totally extinct, under the well-marked phenom- 
T^fl°^ alcoholic poisoning and degeneracy. The effects entailed were: in 
the first generation, alcoholic excesses, immorality, depravity, brutish disposi- 
tion; m the second generation, hereditary drunkenness, attacks of mania, 
general paralysis; in the third generation, sobriety prevailed, but hypochon- 
driases, lyppmania, persistent ideas of persecution, homicidal tendencies, were 
expressed; in the fourth generation, intelligence was but feeble, mania became 
developed at sixteen years of age, stupidity running on to idiocy, and to a con- 
dition involving the extinction of the race. The late Sir James Clark also 
made the observation, many years ago, as the result of his experience, that 

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278 TOPICS RELATIVE TO PATHOLOGY. 

the constitutions of the past three generations had deteriorated progressively 
from father to son (^Treatise on Pulmonary CoTtswnption, p. 11). 

The persistent pernicious influence of the marsh poison will be fully noticed 
in subsequent pages ; but there are other abundant sources of constitutionally 
morbid influences ; and, whatever the explanation may be, it certainly is a 
matter of fact, as the late Dr. Alison wrote, that the constitutional affections, 
going along with the same extent of inflammation and its local eflTects, are 
extremely various in difierent persons previously alike in good health, or even 
in the same person at difierent times; and that we are not entitled to deny 
that what happens in this way in different individual cases may not happen 
also in nations and in seasons. We are still very imperfectly informed as to 
the mode in which any local inflammation excites constitutional fever, and 
we have no reason to doubt that the constitutional reaction consequent on the 
excitement of a certain degree of inflammation of the lungs may vary, equally 
as that which is consequent on the introduction of a certain quantity of the 
poison exciting typhus fever, measles, scarlatina, or cholera; in all of which the 
previous muscular strength goes for nothing in determining the degree or 
danger of depression or debility which may ensue. 

Dr. Christison has recently communicated to the Medico-Chirurgical Society 
of Edinburgh his experience relative to the changes which have taken place 
in the constitution of fevers and inflammations in Edinburgh during the forty 
years previous to 1857. His experience, as well as that of many of the older 
physicians of Edinburgh, shows that a transition had (and did every now and 
then) ta!^en place from an inflammatory or sthenic form of fever to one of an 
asthenic type; that it was necessary, on the outburst of any epidemic, to' watch 
carefully the early cases, to observe the mode in which the fatal cases termi- 
nate, and to observe generally the constitutional tendency or type of individual 
cases, in order to form an accurate judgment of the general character of the 
epidemic about to prevail. It will be seen also, on referring to the most 
approved and recent works on the diseases of India, that the descriptions of 
inflammations as well as fevers now seen there, when compared with the state- 
ments of Dr. Johnson, Mr. Twining, and others, twenty-five or thirty years 
ago, may be held to indicate that there has been a change in the usual form 
oi reaction in inflammatory diseases in that climate as well as here. Such con- 
clusions may be inferred from the experience of Dr. Morehead, recorded in 
his Clinical Researches on the Diseases of India (vol. ii, pp. 71, 72, and 359); 
and the experience of Sir Ranald Martin, expressed in his recent classic work 
on Climate, bears out the same observation. Consult also Graves's Clinical 
Medicine, vol. i, p. 303, for the doctrines of Autenrith and Graves on the 
change of type in disease ; and for evidence regarding the deterioration of 
race, see p. 105 of Mr. Simon's Third Report on the Health of Towns. 

It appears evident, therefore, that the human body is capable of undergoing 
various alterations as regards not only its physical, but also what has been 
termed its " Medical Constitution," from causes known as well as unknown. 
Fevers are known to change their types ; epidemics to assume new tendencies ; 
and inflammations and heal lesions to affect in no constant manner the consti- 
tution of individuals at the same period, or at different times and in different 
countries. This view of the subject may be summed up in the eloquent lan- 
guage of Dr. Watson, when he writes, — " I am firmly persuaded, by my own 
observation,^ and by the records of medicine, that there are waves of time 
through which the sthenic and the asthenic characters of disease prevail in suc- 
cession, and that we are at present living in one of its adynamic phases " 
{Edinburgh Monthly Journal, June, 1857). It must be admitted, however, 
that much of what is written and here quoted regarding changes of type is 
based on the uncertain impressions of individual men, sometimes handed down 
by tradition, rather than based on the results of a deliberate deductive inquiry , 
from statistics applied to the question by men agreed as to the meaning of 



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DEATH BY EXTREME OLD AGE. 279 

terms. On the other hand, I think Dr. Markham, in his very able Gulston- 
ian Lectures on " The Uses of Bloodletting in Disease," puts, the evidence 
regarding change of type in disease on much too narrow a basis — not to say 
an erroneous one — when he holds that it is merely an excuse put forward for 
a change of practice in inflammations, and that the only argument in favor 
of such a theory rests upon the assumed conclusion that venesection produces 
different effects now from what it formerly did. 

A somewhat similar view of this important subject has been ably advocated 
by Dr. J. H. Bennett, of Edinburgh. He contends that inflammation is the 
same now as it has ever been — that the analogy sought to be established 
between it and the varying types of fevers is fallacious — that we cannot place 
reliance on the recorded experience of the past — and that our recent changes 
in therapeutics are solely due to an advanced knowledge of diagnosis and 
pathology (Principles and Practice of Medicine, p. 267). 

The local phenomena of inflammation are undoubtedly constant ; but the 
question of change of type has reference to the constitution of the individual, 
and to the constitutional modes by which the inflammatory state is expressed 
in a given number of persons. Much of the argument of Drs. Markham and 
Bennett appears to me to be beside the question ; and there are certainly good 
grounds for believing that elements of constitutional degeneration exist in such 
abundance, especially in the communities of large towns, that Dr. Watson 
has, I think, happily expressed the consequence of such deterioration in the 
sentence quoted from his writings on the subject. 



CHAPTER X. 

MODES BY WHICH DISEASES TERMINATE FATALLY. 

OuE knowledge on this subject is derived chiefly from three sources, namely, 
from the examples and illustrations afibrded by the study of — (1.) Death from 
old age ; (2.) Death from fatal injuries ; (3.) The powers and actions of all 
our best remedies. Such study leads to the important practical conclu- 
sion, that the same lesions of important organs may prove fatal in very dif- 
ferent ways, both in aqide and in chronic disease, and the fatal event may be 
averted by very different and very opposite remedies (Alison). It is also to 
be observed, that in constitutions which are unimpaired, and, indeed, in every 
morbid process, there may be recognized a tendency to a spontaneous favora- 
ble termination. 

Death happens either from the decay of life, as in old age ; or from rapid 
sinking of the vital powers in acute diseases, as in adynamic fevers. It may 
happen, also, as an accident caused by some of those untoward lesions or 
derangements of the vital organs which occur in the course of the various 
diseases and injuries to which mankind is liable ; as, for example, from fatal 
hemorrhage before exhaustion has reached its utmost, as in some diseases of 
the lungs and digestive canal. 

Death by extreme old age may be considered in many instances as the desira- 
ble end of a long-continued and, perhaps at the end, a dreary journey. The 
sufferer appears to fall asleep as he might do after severe fatigue ; and the 
long and weary pilgrimage of life is thus often brought to a close with little 
apparent derangement of the ordinary mental powers. The final scene is often 
brief, and the phenomena of dying are almost imperceptible. The senses fail, 
as if sleep were about to supervene ; the perceptions become gradually more 
and more obtuse, and by degrees the aged being seems to pass into his final 

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280 TOPICS RELATIVE TO PATHOLOGY. 

slumber. We scarce can tell the precise instant at which the solemn change, 
from life to death has been complet^ed. Sensation fails first, then voluntary 
motion ; but the powers of involuntary muscular contraction, under the excite- 
ment of some external stimulus, may continue for some time longer to be 
feebly expressed. The blood at first generally ceases to be propelled to the 
extremities. The pulsations of the heart become less and less efficient. 
The vital fluid fails to complete its circuit, so that the feet and hands 
become cold as the blood leaves them, and the decline of temperature 
gradually advances to the central parts. Thus far the act of dying seems to 
be as painless as that of falling asleep ; and those who have recovered after 
apparent death from drowning, and after sensation has been totally lost, assert 
that they have experienced no pain. What has unfortunately been called the 
agony of death may therefore be presumed to be purely automatic, and there- 
fore unfelt. The mind at that solemn moment may be absorbed with an 
instantaneous review of those impressions made upon the brain in bygone 
times, and which are said to present themselves with such overwhelming 
power, vividness, and force, that, in the words of Montaigne, " we appear to 
lose, with little anxiety, the consciousness of light and of ourselves." At such 
a time the vivid impressions of a life well spent must constitute that euthanada — 
that happy death — so much to be desired by all. 

The untoward lesions or derangements of vital organs, which occur during 
the progress of disease, terminate the life of man by various modes of dying. 
While it is ordained that eventually all must die, yet it is possible sometimes, 
to avert, for a time, the tendency to death. To know by what agents this, 
may be properly accomplished, it is necessary to know the modes in which 
death may approach in disease. Dr. Watson has happily observed that life 
rests upon a tripod, whose three vital supports are, the heart, the brain, and 
the lungs. Through the impaired functions of some one or more of these 
organs the tendency to death is expressed. The mode of dying may begin at 
the head, the heart, or the lungs (Bichat). But inasmuch as the functions of 
these organs are mutually dependent upon each other, so impairment of func- 
tion in any one of them may ultimately lead to death, while the mode of dying 
is expressed chiefly through the functions of another. The mode of dying in 
disease is usually a complex one, for many parts thus mutually dependent on 
each other are more or less immediately involved. Therefore it is of the 
greatest practical importance to observe how and when the different functions 
begin to languish, and how they may be best sustained in their exertions to 
maintain life. 

Death by Syncope. — When a person loses blood to such an extent that he 
faints, as from a wound, or by hemorrhage occurring in disease, and if the flow 
of blood is not arrested, the state oi faint or syncope continues, is not recovered 
from, and the heart's action ceases ; not because it is unable to contract, but 
because its natural stimulus, the blood, is withdrawn from it, or does not arrive 
in sufficient quantity to be of use. This is called death hy anaemia. In such 
cases, if blood can be tim^ously supplied to the heart (as by the operation of 
transfusion from a healthy person into the patient who is losing blood), the 
suspended function of the heart may be restored, and a supply of blood, suffi- 
cient to maintain life for a time, may be thus obtained. 

The symptoms of approaching death by this mode of dying are paleness of 
the countenance and lips, cold sweats, dimness of vision, dilated pupils, vertigo, 
a slow, weak, irregular pulse, and speedy insensibility. If the hemorrhage 
ias been sudden, in large quantity, as from the uterus in " flooding," there 
may be nausea, or even vomiting, restlessness, tossing of the limbs, irregular 
sighing, breathing (anxietas), delirium, and one or two convulsions before 
death ensues. 

Death by Asthenia. — But another mode of death may be ndore immediately 
■connected with the heart itself, and be independent of the supply of blood. 



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DEATH BY SUFFOCATION OK APNCBA. 281 

In Other words, the stimulus from blood may be sufficient, but the contractile 
power of the organ may fail. Such a mode of death is by aatlienia. Many 
poisons act m this way, and many diseases which are due to morbid poisons in 
the bipod tend to prove fatal by this mode of dying. Cases of extensive mor- 
tihcation of parts, of acute inflammation of the peritoneum, and of malignant 
cholera, die m this way. 

The signs of death approaching by asthenia consist in the pulse becoming 
teeble and frequent, and ultimately failing altogether to be perceived. ThI 
muscular debility becomes extreme, but the senses remain